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UtS.NAVY 



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August 197i 









VADM WUlard P. Arentzen, MC, USN 

Surgeon General of the Navy 



EDITOR 

Sylvia W. Shaffer 

MANAGING EDITOR 

June Wyman 

ASSISTANT EDITOR 

Virginia M. Novinski 

EDITORIAL ASSISTANT 

Nancy R. Keesee 

CONTRIBUTING EDITORS 

Contributing Editor-in-Chief: 
CDR C.T, Cloutier (MC) 
Aerospace Medicine: CAPT M.G. Webb 
(MC); Dental Corps: CAPT R.D. Ulrey (DC); 
Education: CAPT J.S. Cassells (MC); Fleet 
Support: LCDR J.D. Schweitzer (MSC); 
Gastroenterology: CAPT D.O. Castell 
(MC); Hospital Corps: HMCM H.S. 
Anderson; Legal: LCDR R.E. Broach 
(J AGO; Marine Corps: CAPT D.R, Hauler 
(MC); Medical Service Corps: LCDR J.T. 
Dalton (MSC); Naval Reserve: CAPT J.N. 
Rizzi (MC, USN); Nephrology: CDR J.D. 
Wallin (MC); Nurse Corps: CAPT P.J. 
Elsass (NC); Occupational Medicine: CAPT 
G.M. Lawton (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT R.W. Steyn (MC); Research: CAPT 
C.E. Brodine (MC); Submarine Medicine: 
CAPT H.E. Glick (MC) 

POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed 10 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each MedieaS, Dental, Medical Service 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed to: Editor, U.S. Navy Medicine, Department of 
the Navy, Bureau of Medicine and Surgery (Code 0010), 
Washington, D.C. 20372. Telephone: (Area Code 202! 
254-4253, 254-4316, 254-4214; Autovon 294-4253, 294-4316, 
294-4214. Contributions from the field are welcome and will 
be psiblished as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor- 
dance with Department of the Navy Publications and 
Printing Regulations (NAVEXOS P-35). 



NAVMEDP-5088 



U.S.NAVY 




Volume 68, Number 8 
August 1977 



1 From the Surgeon General 

2 Department Rounds 

Open letter to the Medical Service Corps . . . Dental Corps: 65 years 
of change . . . Aerospace medicine honors its own 

10 BUMED SITREP 

11 Notes and Announcements 

Dental continuing education courses . . . Navy occupational health 
workshop . . . Continuing education for Navy nurses . . . Public 
Health Service offers medical seminars 

12 Policy 

Preventing respiratory therapy hazards . . . Instructions and directives 

15 Scholars' Scuttlebutt 

Graduate medical education program directors . . , Will you get 
the internship you want? 

16 On Duty 

A Medical Officer Deploys to the Indian Ocean 
LCDR K.L. Andrus, MC, USNR 

18 Features 

Use of Inpatient Adjunct Services in Naval Hospitals 
LCDR R.A. Pay ton, MSC, USN 
LTW.L. Roach, Jr., MSC, USN 

22 Education and Training 

Teaching Diabetic and Cardiac Patients; New Guidelines 
CAPT J.S. Shaw, NC, USN 
LCDR J.H. Smith, NC, USN 

23 CPR Training at Pax River 

24 Clinical Notes 

Simplified Record-Keeping for a Centralized Intravenous 

Admixture Program 

LCDR L.L. Karch, MSC, USN 

LCDR W.F. Morris, Jr., MSC, USN 

LT W.A. Ollenburg, MSC, USN 

26 Professional 

The Technique of Transpyloric Feeding 
CDR B.S. Saunders, MC, USN 
CAPT R.J. Chutter, DC, USN 
CAPT W.M. Bason, MC, USN 

COVER: LCDR A.F. Mataldi (MSC), an environmental health officer with 
Environmental and Preventive Medicine Unit No. 2, inspects the interior of 
a dishwasher aboard a Navy ship. The role of environmental health officers 
in the Navy is one of the topics discussed in an open letter to Medical 
Service Corps officers, beginning on page 2. 



From the Surgeon General 



Put Caring Back into Patient Care 



IN THE JANUARY 1977 issue of 
U.S. Navy Medicine, I made it clear 
that I consider our prime responsi- 
bility to be the care of our patients, 
and suggested certain areas where 
close attention should be paid, lest 
we inadvertently sabotage our ef- 
forts. 

With the massive technological 
complexity of modern medicine and 
the attendant increases in numbers 
of personnel required, a disturbing 
fragmentation and distortion of 
health care has occurred. Patients 
become interesting cases or puz- 
zling laboratory problems instead of 
people needing help. Indeed, our 
ability to split apart and analyze 
virtual ly every product of the human 
body has led us to the ultimate ab- 
surdity— "abnormalities" in search 
of a disease. 

People have illnesses. People get 
sick. We must recognize that and 
deal with that. People seek help, 
medical or otherwise, when their 
anxiety has gone beyond their indi- 
vidual abilities to deal with it. We 
must assist them in dealing with 
that anxiety. The attitudes we 
present are crucial in determining 
our effectiveness. The outcome may 
be good; the process may have been 
psychologically disastrous. The way 
we measure our effectiveness is not 
the same as the way our patients 
measure it. 




VADM Arentzen 



There are those who abuse our 
system. But it is unfair and untrue 
to so categorize the majority of the 
patients we serve. 

Physicians and nurses should, of 
course, be acutely conscious of pa- 
tient anxiety, but it is equally the 
responsibility of every person who 
interacts with a patient. Staff mem- 
bers who make the initial contact 
with patients at the admission desk, 
the clinic desk or the telephone can 
easily destroy any rapport that may 
have existed before, can make op- 
ponents of our supporters. 

A friendly smile, a pleasant voice, 
an air of concern are worth any 



number of pharmaceutical nos- 
trums. The simple act of listening is 
the best tranquilizer in the world. 
The manner of access to health care 
is just as important to the patient's 
perception of his experience as is 
the care itself. We all know these 
things instinctively, but in the pres- 
sures of daily demands they are 
sometimes forgotten. That must not 
happen. 

I have asked our medical facility 
commanding officers to institute 
training programs for those individ- 
uals who work in the initial contact 
areas to help them understand how 
very important they and their jobs 
are. We must institute patient edu- 
cation programs to reduce inappro- 
priate utilization of facilities. A co- 
operative effort is essential, particu- 
larly with our present physician 
shortfall, if we are to accomplish our 
mission with the least possible 
disruption of services. 

Unless we care, and show we 
care, that cooperation cannot be 
gained. Put caring back into patient 
care! 



M 




W.P. ARENTZEN 

Vice Admiral, Medical Corps 

United States Navy 



Volume 68, August 1977 



Department Hounds 



Open Letter to the Medical Service Corps 



In this, my first letter to officers 
of the Medical Service Corps, I want 
to express my appreciation for the 
outstanding job you have done in 
the past year. From your associates 
in the Medical Department, from 
line officers, and from our patients, 
I constantly hear words of praise for 
the services you perform. I am cer- 
tain that you are true professionals 
dedicated to the tasks and mission 
of the Medical Department, and I 
urge you to continue this fine tradi- 
tion of service to Navy medicine. 

The Corps in '77, I would like to 
tell you about the areas we are 
emphasizing this year and what the 
future holds for us. I will focus on 
the Medical Service Corps' emerg- 
ing role in support of the operating 
forces, contributions to patient care, 
participation in efforts to improve 
industrial, occupational and aviation 
safety, and improvements in man- 
agement of Navy medical facilities. 

Pharmacy. Plans are under way 
to expand the unit dose drug distri- 
bution system. This system allows 
pharmacists to interpret physicians' 
original drug orders and dispense to 
the ward only doses which have 
been ordered. The system contrib- 
utes to better patient care by allow- 
ing pharmacists to maintain drug 
profiles which list the patient's diet, 
diagnosis, drug allergies, and drug 
sensitivities, as well as other medi- 
cal information. Using this informa- 
tion, the pharmacist screens physi- 
cians' orders for possible drug-drug 
or food- drug interactions, drug 
allergies, improper dosage regi- 
mens, and drug overlaps. Through 
this additional check, pharmacists 
can control and distribute drugs 
more efficiently, and fewer doses 
are wasted. 

Aviation medicine. Naval aviation 
physiologists continue to expand 
their support of the operational 



forces. Many new initiatives, as 
well as significant progress in es- 
tablished aviation physiology en- 
deavors, were assessed during a 
program review conducted at the 
Bureau of Medicine and Surgery 
this spring. Particularly noteworthy 
is the Aviation Medicine Safety 
Officer (AMSO) Program. The ori- 
ginal 12 AMSO billets established 
to provide direct support to fleet 
readiness are being expanded to 18; 
our goal is to have 21 aviation phys- 
iologists in the program. This ex- 



Curricula and resource manage- 
ment for the Naval Aviation Physi- 
ology Training Program and Naval 
Aviation Water Survival Training 
Program are being revised. Also, 
several new training devices now in 
the planning or procurement stages 
will generate new challenges for 
students in these programs. Many 
currently used training devices are 
being modernized and modified. 

Additional emphasis has been 
placed on research and develop- 
ment in the Naval Aviation Physiol- 




--*•.>,& 



Environmental health officer measures food temperature aboard USS Iwo Jima 



pansion of the program will give 
aviation physiologists more oppor- 
tunities to work in areas such as ac- 
cident prevention, accident investi- 
gation, and improvement of survival 
and rescue techniques. Naval air 
stations in Beaufort, S.C., and 
Hawaii, and the Chief of Naval Air 
Training have priority for these new 
AMSO billets. We are also consid- 
ering adding two experimental psy- 
chologists to the AMSO Program to 
investigate and analyze psychologi- 
cal and physiological factors affect- 
ing human performance in aviation. 



ogy Program. New career patterns 
are being developed, with current 
plans calling for more billets for 
aviation physiology researchers. 

We are looking into the possibility 
of working with the Air Force to 
train aviation physiologists as well 
as aircrew personnel. There are now 
officer exchange programs at Naval 
Air Station Barbers Point and 
Andrews Air Force Base. 

Environmental health. During the 
past year, increasing requirements 
to support the operating forces have 
created heavy demands on our 



U.S. Navy Medicine 




Industrial hygienist conducts heat stress 
survey using wet bulb globe tempera- 
ture index meter 



environmental health officers. Rou- 
tine environmental health surveys 
mandated by CINCPACFLT and 
CINCLANTFLT for all ships have 
increased the number of ship visits 
made by Medical Department per- 
sonnel from our environmental and 
preventive medicine units and some 
naval regional medical centers. As a 
result of these visits, shipboard en- 
vironmental health problems are 
being identified and addressed at 
headquarters level. Through the ef- 
forts of environmental health offi- 
cers, changes are being instituted in 
ship design and construction to en- 
hance shipboard environmental 
health. 

Environmental health officers at 
naval regional medical centers have 
been called on more and more to 
assist fleet units, particularly ships 
far from environmental and preven- 
tive medicine units. These officers 
are evaluating the health aspects of 
new projects — such as a waste 
water recycling system in Navy 
housing in Norfolk. Environmental 
health officers have also helped 
develop health standards and prac- 
tices for sewage collection, holding, 
and transfer systems aboard Navy 
ships, They have evaluated a new 
design for shipboard bromination 
systems and new, more efficient 
shipboard garbage grinders. 

At shore activities, environmental 



health officers have reviewed plans 
and provided on-site consultation 
for food service facilities under con- 
struction and renovation. They have 
reviewed and given advice on the 
design and construction of sewage 
hose cleaning and storage facilities 
at fleet activities. Occupational 
health demands are being met by 
environmental health officers at 
several activities that do not have 
industrial hygienists. 

Environmental health officers 
often participate in IG inspections of 
Marine Corps and Naval Supply 
Systems Command activities. The 
Naval Board of Inspection and 
Survey requests environmental 
health officers to participate in 
health inspections conducted 
aboard aircraft carriers. Indeed, 
this expertise is in such demand 
that an environmental health officer 
will be assigned to one of the sub- 
boards of the Naval Board of Inspec- 
tion and Survey. 

Because of Joint Commission on 
Accreditation of Hospitals (JCAH) 
emphasis on environmental safety 
in hospitals, environmental health 
officers are playing a bigger role on 
hospital infection control commit- 
tees and in investigating the many 
facets of hospital environmental 
health. 

Industrial hygiene. Industrial hy- 
gienists continue to take a major 
role in operational medical support. 
Stationed at rapid response units 
such as the Navy Environmental 
Health Center and environmental 
and preventive medicine units, 
industrial hygienists respond to 
requests for surveys on ships, 
among their other functions. By 
conducting these surveys, industrial 
hygienists help commands recog- 
nize, evaluate and control occupa- 
tional hazards arising from chemical 
or physical stress. Industrial hy- 
gienists conduct heat stress and 
noise surveys to fulfill Navy inspec- 
tion requirements, and help com- 
mands interpret and apply regula- 
tions set by the Occupational Safety 
and Health Administration. 

Future plans for our industrial 
hygienists include stationing them 



at major naval regional medical 
centers to augment occupational 
medicine services — a development 
that will nearly double the number 
of Navy industrial hygienists. 

Clinical psychologists. Clinical 
psychology gained wider profes- 
sional recognition during World 
War II because of its contributions 
to the psychodiagnostic testing of 
military personnel. Military clinical 
psychologists, well trained in re- 
search skills, have contributed to 
the foundations of scientific knowl- 
edge by developing techniques to 
screen people for Antarctic duty and 
to judge performance of people 
serving in isolated areas. More 
recently, Navy clinical psychologists 
have investigated psychiatric dis- 
orders among Navy and Marine 
Corps personnel, as well as the 
causes and consequences of alcohol- 
ism. 

In the Navy, clinical psychologists 
have assumed a larger role in direct 
patient care. Through neuropsy- 
chological assessment of brain dys- 
function, for example, clinical psy- 
chologists broaden the use of psy- 
chological tests and measures as 
aids to differential diagnosis. Clini- 
cal psychologists have also made 
contributions to the development of 
innovative intervention and treat- 
ment techniques. They routinely 
evaluate outpatients, and conduct 
individual and group psychotherapy 
for inpatients and outpatients in 
psychiatric, alcohol rehabilitation, 
and drug rehabilitation facilities. 

A recent development is the con- 
version of several Medical Corps 
psychiatry billets to Medical Service 
Corps clinical psychology billets. 
This greater leadership responsibil- 
ity for clinical psychologists is con- 
sistent with trends of the past 
decade in Navy medicine and 
civilian mental health practice: the 
multidisciplinary team is becoming 
predominant, with an emphasis on 
working directly with community 
mental health agencies. Clinical 
psychologists, trained in the com- 
munity mental health approach, 
have been leaders in implementing 
"outreach" approaches to prevent 



Volume 68, August 1977 



or alleviate mental disorders. In our 
regional medical centers and hospi- 
tals, clinical psychologists increas- 
ingly refer patients to almost every 
medical service. 

Direct consultation to operational 
and training commands is an im- 
portant example of the role increas- 
ingly filled by the clinical psycholo- 
gist. For several years, Navy clinical 
psychology has provided the only 
mental health and training consulta- 
tion to the Navy's Survival, Evasion, 
Resistance, and Escape bases in 
Maine and California. Another five 
MSC clinical psychologists now 
work full-time at the Naval Acad- 
emy as course coordinators, in- 
structors, consultants to aptitude 
and academic boards, and research- 
ers, as well as clinicians. These of- 
ficers also provide a psychology 
emergency watch for Naval Hospital 
Annapolis. The Alcohol Rehabilita- 
tion Center at San Diego, the three 
naval training centers, and the two 
Marine Corps recruit depots are 
other examples of line commands 
with full-time MSC clinical psychol- 
ogists. 

The new alcohol rehabilitation 
service at Portsmouth, Va., will 
have a full-time MSC clinical psy- 
chologist. A new MSC clinical 
psychology billet at Naval Hospital 
Patuxent River, Md. t will provide a 
much needed full-time consultant 
for the expanding naval air station 
and flight test center. The Marine 
Corps Air Station at Cherry Point, 
N.C., also has a new full-time billet 
for an MSC clinical psychologist. A 
new billet has been created for an 
MSC clinical psychologist who will 
provide full-time consultation to the 
fleet in Mayport, Fla. 

These trends toward direct pa- 
tient service and consultation to the 
fleet are expected to continue. The 
number of Navy clinical psychology 
billets increased 38% in FY77. 
Some 55% of our currently commis- 
sioned clinical psychologists were 
augmented from the Reserve, and 
approximately 60% have prior mili- 
tary service. 

Health systems management. Al- 
though the average length of inpa- 



tient stay (ALOS) for active- duty 
members is only one indicator of 
noneffective time, this statistic is 
widely used by regulators to assess 
the efficiency of the Navy health 
care system. We have made great 
progress in reducing the average 
length of inpatient hospitalization in 
our facilities: in FY75 the ALOS for 
active-duty Navy and Marine Corps 
inpatients in Navy medical facilities 
was 19.7 days; that average went 
down to 12.5 days in FY76 and 7.9 
days in March 1977. Partly as a re- 
sult of more efficient inpatient 




LT Pal Cronin (left) and LT Terry Irgens 
screen drug orders at NNMC 

administration programs, the ALOS 
for active-duty inpatients has de- 
creased approximately 60%. In 
March 1977 the ALOS for all pa- 
tients in naval medical facilities was 
6.5 days, compared to 7.4 days for 
patients in short-term, acute care 
civilian hospitals. 

In providing quality health care 
services to our active-duty mem- 
bers, we will continue to emphasize 
reducing the time these men and 
women are noneffective. Further 
improvement in ALOS may be 
obtained if we stay aware of alterna- 
tives to continued inpatient care, 
improve the timeliness and effec- 
tiveness of administrative process- 
ing, and apply utilization review 



procedures. Medical Service Corps 
officers are contributing in all these 
areas by conducting innovative and 
progressive systems analyses and 
by providing good management 
support. 

Word processing systems. Word 
processing systems — the use of 
specialized, full-time personnel and 
automated equipment to process 
paper work efficiently — have great 
potential to improve our administra- 
tive support services. In Navy medi- 
cal centers and hospitals, word 
processing systems are enabling us 
to centralize dictation and transcrip- 
tion of medical and administrative 
reports. Some facilities use shared- 
logic mini-computers in their word 
processing systems: Naval Regional 
Medical Center San Diego, for ex- 
ample, set up a COMPUTEXT mini- 
computer system in November 1975 
with excellent results, and similar 
systems are being installed at the 
National Naval Medical Center and 
Naval Regional Medical Center 
Portsmouth. 

The Medical Service Corps offi- 
cer's role in evaluating word proc- 
essing innovations is to provide the 
systems analysis and management 
expertise we need to plan, develop, 
implement and maintain these vital 
administrative support systems. 
Word processing gives us an oppor- 
tunity to use our personnel more ef- 
ficiently, to edit and process more 
documents in a given time, and to 
improve the quality and timeliness 
of medical records. Word process- 
ing will allow us to process docu- 
ments better and faster, and to in- 
crease the cost effectiveness of 
administrative support functions. 

Contact point management. To 
promote cooperation and under- 
standing between providers and 
consumers of our medical services, 
naval medical facilities have set up 
health care consumers' councils and 
patient education programs. In 
conjunction with those efforts, we 
can improve service at patient con- 
tact points. Medical Service Corps 
officers should lead in setting up 
programs to train people who work 
in areas where they have direct 



U.S. Navy Medicine 




LTJG Doris Forte uses ophthalmoscope to examine young patient 



contact with patients. Responsive, 
individualized help, given courte- 
ously and compassionately, can 
benefit not only the patient but also 
the treatment facility. 

Personnel. Directing our atten- 
tion to support of the operating 
forces has raised several questions 
this year. For example, there is a 
shortage of MSC volunteers for duty 
with the Fleet Marine Force. Duty 
with the Fleet Marine Force gives 
MSC officers an excellent opportu- 
nity to assume great responsibility 
early in their careers, and to obtain 
outstanding training and valuable 
experience. Tours with the Fleet 
Marine Force lead to progressively 
higher levels of responsibility not 
otherwise available to MSC officers. 
Officers who wish to serve with the 
Fleet Marine Force should inform 
the MSC detailer at BUMED, either 
by submitting a new preference 
card or by telephone. We will make 
every effort to honor such requests. 

Augmentation. Augmentation is 
the procedure by which a Reserve 
MSC officer (designator 2305) or 
temporary MSC officer (2302) can 
extend his or her contractual status 
to indefinite as a Regular naval of- 



ficer (2300). The advantages of 
augmenting in the Medical Service 
Corps are many, and include: 

• Guaranteed 20 years' commis- 
sioned service after the augmented 
officer attains LCDR rank. 

• Opportunities for full-time out- 
service training. 

• Overseas assignments which re- 
quire a service obligation beyond 
the contractual limits assigned a 
Reserve officer. 

• Career security not available to 
Temporary and Reserve officers. 

Because we do not now have a 
quota for Regular MSC officers, 
Temporary and Reserve officers do 
not compete against each other for a 
limited number of augmentation 
opportunities. Each officer who 
applies for augmentation is evalu- 
ated by a selection board which 
meets twice a year. The officer's 
record along with the command 
endorsement are the major items 
evaluated for selection. Information 
about augmentation can be found in 
the BUPERS Manual, Article 
1020120. 

Training. It appears that the 
Medical Service Corps will be able 
to continue its support of all training 



programs, including inservice, out- 
service and part-time training. The 
number of training billets projected 
has not changed, and we expect that 
about 100 MSC officers can be 
retained in full-time education pro- 
grams at any one time. 

In a move to make health care 
administration training more cost 
effective, we have ordered three 
officers to the Army/Baylor Univer- 
sity Program at Fort Sam Houston, 
Tex., leading to a master's degree 
in health administration. This pro- 
gram, along with Navy Postgradu- 
ate School programs in financial 
management, personnel manage- 
ment and computer systems man- 
agement, will provide the bulk of 
our health care administration train- 
ing. 

Training billets will continue to 
be allocated for the various special- 
ties. All full-time training must be 
justified by a requirement for some- 
one with that training and lack of a 
qualified officer to fill the billet. Of- 
ficers interested in applying for full- 
time training should review the BU- 
MED Instruction 1520.12 series. 
■ 

The year 1977 and 1978 offer 
many challenges and opportunities 
for the Medical Service Corps. I 
urge each of you to meet these chal- 
lenges by making your own unique 
contributions to better patient care. 
The Medical Service Corps is a 
group with great expectations and 
unlimited promise, and the military 
community you serve will rely more 
and more on you in the future. I ask 
you to resolve not to disappoint the 
people who look to you for help, and 
thereby not disappoint yourselves. I 
have the greatest confidence in your 
loyalty and ability. 

I thank you for your fine effort 
and support in the past. Keep up 
the good work! 




W.J. Green, Jr. 

Captain, Medical Service Corps 

United States Navy 



Volume 68, August 1977 




Mobile unit provides dental care aboard ship This portable eauipment used todav to provide dental care in the field 

g U.S. Navy Medicine 



Dental Corps 



65 Years of Change 



The Navy Dental Corps marks its 
65th anniversary this month. The 
past 65 years have brought many 
changes in dental care provided to 
the active naval forces — changes 
motivated by the need to keep pace 
with advances in dental technology 
and materials. 

Growth. The need for military 
dentistry was recognized as early as 
1844 by Edward Maynard, M.D., 
D.D.S., a well-known practitioner of 
dentistry in Washington, D.C. But 
not until 22 Aug 1912 did Congress 
pass an Act establishing the Navy 
Dental Corps and authorizing the 
Secretary of the Navy to appoint 30 
acting assistant dental surgeons. 
From those first 30 dental officers, 
the Dental Corps has grown to to- 
day's force of approximately 1,700 
active-duty officers. These men — 
and now six women — are supported 
by nearly 3,000 dental technicians, 
some 65 Medical Service Corps offi- 
cers, and more than 380 Navy civil- 
ian employees. 

When the 1912 legislation was 
enacted, Congress appropriated 
only $15,000 for dental outfits, 
dental materials, and other neces- 
sary expenses. By today's standards 
that funding was modest. Since 
then, the changes have been im- 
pressive — our active naval forces 
now enjoy modern, comprehensive 
dental care ashore and afloat. 

Regionalization. The latest inno- 
vation in Navy dental care is the 
dental regionalization program. 
Through effective command man- 
agement as well as technical control 
over dental procedures, regionaliza- 
tion has improved dental care deliv- 
ery and led to a notable increase in 
the treatment accomplished by each 
dental officer. This increase in pro- 
ductivity has resulted in marked 
improvement in the dental health of 
Navy members (see chart). For 
example, the percent of Navy mem- 
bers who needed no dental treat- 



ment increased from 39.4% in 1975 
to 48.6% in March 1977. 

The Dental Corps continues to 
improve dental care for the active 
naval forces through effective re- 
source allocation, dental research, 
and education. Inservice training 
programs for dental officers — resi- 
dencies, postdoctoral fellowships, 
and continuing education courses — 
are structured to meet the Navy's 
requirements for dental officers 
with specific skills. These training 
programs ensure up-to-date care for 
Navy members by keeping dental 
officers in the field abreast of new 
developments in dentistry. 

Top priority has been given to 
developing a quality review mecha- 
nism for procedures most commonly 
performed in Navy dentistry. Guide- 
lines developed to objectively evalu- 
ate the quality of clinical treatment 
are now being tested in pilot proj- 
ects. 

To improve management, the 
Dental Corps is testing a dental in- 
formation retrieval system. When 
fully operational, this automated 



data processing system will provide 
Corps managers with a wide array 
of data to use in assessing the 
dental treatment needs of active- 
duty members and the professional 
accomplishments of dental officers. 
The information will be invaluable 
in deciding how to allocate re- 
sources. 

Annual exams. The primary mis- 
sion of the Dental Corps is to 
provide dental care for active-duty 
Navy and Marine Corps personnel 
so as to ensure their combat readi- 
ness. Many Navy members seek 
treatment on their own initiative — 
but some do not, and there is a need 
to identify and treat dental disease 
in these people. To identify these 
members, and to better assess den- 
tal treatment requirements of all 
active-duty personnel, an annual 
dental examination is now required 
for active-duty members. Dental 
facilities must maintain close con- 
tact with all levels of command to 
coordinate these examinations. An- 
nual examinations will allow earlier 
detection, diagnosis and treatment 
of dental disease; thus the Dental 
Corps will have a clearer idea of 
future workloads and will be able to 
plan more efficient use of dental 
personnel. Line commanders will be 
able to manage their personnel 



Dental Health Profiles, 1975 and 1977 



Classification 


Percent of active-duty Navy members 
in each class 




September 1975 


March 1977 


Class I— people requiring no 
dental treatment 


39.4% 


48.6% 
39.8% 


Class II— people who need 
routine but not early treatment 


40.5% 


Class III— people requiring 
early treatment 


17.3% 


9.8% 


Class IV— people who require 
essential prosthetic appliances 


2.0% 


1.8% 


Class V— people requiring 
emergency treatment 


.02% 






Volume 68, August 1977 



more effectively when these com- 
manders know which members re- 
quire treatment. 

A standardized system for exam- 
ining patients and classifying them 
into treatment categories has been 
developed. By providing explicit 
classification criteria, this revised 
system enables dental officers to 
better determine: 

• urgency or priority for treating an 
individual. 

• patient's treatment needs and 
suitability for transfer to areas 
where dental support is minimal. 

• operational readiness of a com- 
mand or unit. 

Also, SECNAV and BUMED direc- 
tives have been issued which em- 
phasize the priority of dental treat- 
ment for members of the Navy and 
Marine Corps operating forces. 

Quality care. The Dental Corps is 
doing everything possible to ensure 
quality care for the most essential 
element of our weapons system: the 
men and women of the Navy and 
Marine Corps. The impressive con- 
tribution made by Navy dental offi- 
cers in support of the Navy's mis- 
sion during the past 65 years pro- 
vides a firm base for meeting the 
challenges of the future. 



First graduating class, U.S. Navy Den- 
tal School, 1923 (right); (bottom) 1977 
graduates from National Naval Dental 
Center, Bethesda, Md. 



DENTAL SHORE FACILITIES 




Dental office in Philippine Islands, 1932 NRDC San Diego, Calif., 1977 



GRADUATE TRAINING 




U.S. Navy Medicine 



Aviation Medicine 



Aerospace Medicine Honors Its Own 



Three Navy flight surgeons were 
honored at the Aerospace Medical 
Association's 48th annual scientific 
meeting, held 9-12 May in Las 
Vegas. 

Receiving the third annual Rich- 
ard E. Luehrs Memorial Award and 
the title "Navy Operational Flight 
Surgeon of the Year" was LT Willis 
E. Martin (MC), a Reservist on 
active duty as flight surgeon for 
Marine Air Group 26 in New River, 
N.C. LT Martin was cited for out- 
standing performance of duty, in- 
cluding support of special missions 
in the Mediterranean. 

"The spartan conditions prefer- 
red to flight surgeons in the Second 
Marine Aircraft Wing have not 
deterred LT Martin's determina- 
tion, ability or professionalism," his 
wing medical officer noted when 
nominating LT Martin for the 
award. 

A native of Roanoke Rapids, 
N.C, Dr. Martin received his M.D. 
degree from the University of North 
Carolina at Chapel Hill and entered 
active duty in July 1975. 

CAPT Joseph A. Pursch (MC) 
received the Raymond F. Longacre 
Award, given annually to recognize 
outstanding accomplishment in 
aerospace psychology and psychia- 
try. A well-known expert on drug 
and alcohol abuse, Dr. Pursch 
directs the Naval Alcohol Rehabili- 
tation Service in Long Beach, Calif., 
where he has pioneered in training 
physicians to recognize and treat 
alcoholism. In 1976 he was named 
the Surgeon General's special as- 
sistant for alcoholism. 

After graduating from the Indiana 
University School of Medicine in 
1959, Dr. Pursch became a Navy 
flight surgeon. Later board certified 
in neuropsychiatry, he served as 
personal physician to the Secretary 
of the Navy, as well as assistant 
chief of the Division of Psychiatry, 
Naval Aerospace and Regional 



Medical Center Pensacola, and 
head of the Neuropsychiatry De- 
partment, Naval Hospital Naples, 
Italy. 

Retired Medical Corps CAPT 
Channing L. Ewing received the 
Eric Liljencrantz Award, given for 
basic research into the problems of 
acceleration and altitude. As chief 
scientist at the Naval Aerospace 




Channing L. Ewing, M.D. 

Medical Research Laboratory De- 
tachment, Michoud, La., Dr. Ewing 
studies human dynamic response to 
crash impact acceleration; his re- 
search will provide the first valid 
data on limits of human tolerance to 
crash impact. He is also conducting 
basic research into the effects of 
severe ship motion on human sub- 
jects. 

Since 1959, Dr. Ewing has been 
studying ways to protect humans 
from the impact of crashes and 
ejections. From 1959 to 1968, he 
conducted all the Navy's in-house 
research and development on crash 
helmets. His development of phys- 
iologically-based crash helmet tests 
for the Army and Navy led him to 
study inertial responses of human 
body segments to impact accelera- 
tion, physiological responses to 




a 



• * 



CAPT Joseph Pursch (MC) 




LT Martin (center) with Mrs. Luehrs 
and RADM R.E. Nauman (MC) 

these inertial responses, and more 
recently, the pathological basis of 
the physiological responses. When 
he retired from the Navy Medical 
Corps last year, Dr. Ewing was offi- 
cer-in-charge of the Detachment 
where he now conducts his re- 
search. 

A graduate of the Medical Col- 
lege of Virginia, Dr. Ewing holds a 
master's degree in public health 
and completed residency training in 
aviation medicine. 



Volume 68, August 1977 



9 



BUMED SITREP 



WEIGHT STAMJARDS . . . Change 91 
to the Manual of the Medical Depart- 
ment gives revised weight standards for 
Navy and Marine Corps men and wom- 
en. However, these new standards 
apply only to individuals being recruited 
— not to personnel already on active 
duty. Once on active duty, Navy and 
Marine Corps members must meet the 
weight standards set forth in BUPERS 
Instruction 6110.2B. 

CORPSMEN NEEDED . . . Two chief 
hospital corpsmen will be needed in an 
independent duty status for Operation 
Deep Freeze '79 to provide medical care 
for civilian scientists working at remote 
stations in Antarctica. The only contact 
with a medical officer will be by radio. 
If you are interested in this unique 
assignment, review BUPERS Notice 
1300 of June 1977 for eligibility require- 
ments. Applicants will be chosen in late 
1977, screened in early 1978, and the 
men selected will deploy to Antarctica 
around October of that year. 

HEAT STRESS ... To combat heat 
stress, salt tablets should be used with 
great caution — and only under medical 
supervision. BUMED Instruction 
6200. 7A of 26 Jan 1977 advises that 
people in hot, humid climates should 
not take more than 2 gm of supplemen- 
tary salt (three tablets) a day. This re- 
striction is particularly important for 
older individuals, who retain more salt. 
The revised instruction describes types 
of heat casualties, such as rash, cramps, 
exhaustion, and stroke, as well as pre- 
ventive measures. 

A new source of heat stress informa- 
tion aimed at a general Navy audience is 
the Navy training film, "The Heat 
Stress Monster." The 27-minute color 
cartoon illustrates right and wrong ways 
to deal with heat and humidity. Video- 
tape cassettes can be ordered now from 
the Audiovisual Resources Division, 
Naval Health Sciences Education and 
Training Command, National Naval 
Medical Center, Bethesda, Md. 20014. 
Prints of the 16 mm film will be avail- 
able in October. 

Production has begun on a more de- 
tailed movie covering the same subject. 
"If You Can't Stand the Heat," a 
Navy training film aimed at supervi- 
sors, should be ready for viewing next 
spring. 



LOCK AND KEY . . . Naval medical 
facilities must establish physical securi- 
ty review committees to assist com- 
manding officers in safeguarding hospi- 
tal property, in line with OPNAV In- 
struction 5510.45B, 

Key rings must be kept in a secure 
locker after normal working hours. Any- 
one who checks keys in or out must sign 
a control log. Master keys should be 
kept only by top managers. Command- 
ing officers must authorize, in writing, 
individuals who may hold keys; a copy 
of the authorization will be placed in the 
member's file jacket. 

TOO MUCH GOLD? . . . According to 
the Navy Audit Service, dental activities 
should maintain only enough gold and 
other precious metals to meet command 



requirements. Excess metals must not 
be sold or exchanged, but should be dis- 
posed of in line with provisions of the 
Defense Disposal Manual, Chapter V. 
Command audit boards should weigh 
and examine bundles of obsolete and 
unused precious metals during inspec- 
tions, to ensure that the precious metals 
inventory is complete and accurate. 

NOTE OF CAUTION ... On arriving in 
foreign ports, shipboard medical de- 
partment representatives should estab- 
lish close liaison with local medical 
authorities to reduce problems in the 
event of a crewmember's death or 
injury. Medical department representa- 
tives should ask about availability and 
phone numbers of local hospitals, 
pathologists, and ambulance services, 
as well as the method of paying for 
these services and local requirements 
for reporting deaths. 



ERRATUM 

Our readers have alerted us to several errors that appeared in ' 'How Med- 
ical Department Officers are Assigned" (US Navy Medicine, April 1977): 

• Reference to normal tour lengths for Medical Department officers in gen- 
eral should be deleted in view of different requirements and types of tours for 
each corps. Tour lengths are determined and projected rotation dates (PRDs) 
assigned in accordance with BUPERS policy for the type of duty and area in- 
volved. An officer's PRD is reflected on the Officer Distribution Control Re- 
port (NAVPERS 1301/5) available at each command. 

• When reassignment is requested either because of documented hardship 
or to be with one's spouse, and when no valid PRD exists, permissive orders 
involving no cost to the government may be issued, providing a valid billet is 
available. 

• Only Medical Corps officers should send requests for extension of active 
duty to the Chief of Naval Personnel via BUMED Code 312. Dental Corps offi- 
cers should send such requests via BUMED Code 613, Medical Service Corps 
officers via BUMED Code 711, and Nurse Corps officers via BUMED Code 
321. 

• The correct reference for information on early release from active duty of 
Reserve officers is BUPERS Manual, Article 3830100. Information concern- 
ing resignation policy for both Regular and Reserve officers is contained in 
the SECNAV Instruction 1920.3 series. 

• ALNAV 082/76 discontinued all early release of officers and enlisted per- 
sonnel for the purpose of attending school — including, but not limited to, 
graduate medical or dental education. 

• The first paragraph of page 18 of the April issue should read (revised ma- 
terial in italics): All Medical Department officers should give assignment 
officers current, pertinent information that might affect their assignability. 
Commands should ensure that copies of officers' reporting and detachment 
endorsements, acceptances of augmentation, and promotion appointments 
are forwarded to the appropriate BUMED codes. Information which should 
be provided in the "Remarks" section of an updated preference card in- 
cludes: number and age of children; spouse's name, civilian occupation or (if 
military) rank/rate year group, social security number, designator, rotation 
date, duty station, and name and telephone number of detailer; spouse's 
school completion date (if a student); spouse's estimated date of confinement 
or delivery, if pregnant. 



10 



U.S. Navy Medicine 



Motes & Announcements 



DENTAL CONTINUING EDUCATION COURSES 

The following dental continuing education courses 
will be offered in November 1977: 

National Naval Dental Center, Bethesda, Md. 

Preventive dentistry 14-16 Nov 1977 

Eleventh Naval District, San Diego, Calif. 

Operative dentistry 7-9 Nov 1977 

U.S. Army Institute of Dental Research, Walter Reed 
Army Medical Center, Washington, D.C. 

Prosthodontics 7-10 Nov 1977 

Requests for courses administered by the Comman- 
dant, Eleventh Naval District, should be submitted to: 
Commandant, Eleventh Naval District (Code 37), San 
Diego, Calif. 92132. Applications for other dental con- 
tinuing education courses should be submitted to: Com- 
manding Officer, Naval Health Sciences Education and 
Training Command (Code 5), National Naval Medical 
Center, Bethesda, Md. 20014. Applications should ar- 
rive six weeks before the course begins. 

Cross-country travel and travel from outside the con- 
tinental U.S. to attend dental continuing education 
courses generally will not be approved due to funding 
limitations. 

NAVY OCCUPATIONAL HEALTH WORKSHOP 

The 20th Navy Occupational Health Workshop will be 
held 7-11 Nov 1977 at the Seattle Hilton Hotel, Seattle, 
Wash. The workshop is directed to physicians, nurses, 
industrial hygienists, medical safety officers and pro- 
gram managers, and should be of special interest to 
people in federal occupational health programs. 

There is no registration fee. For further information, 
write to the Navy Environmental Health Center, 3333 
Vine Street, Cincinnati, Ohio 45220. Or phone (Area 
code 513) 684-3863 or Autovon 989-3863. 

CONTINUING EDUCATION FOR NAVY NURSES 

In the latter part of 1977, the Naval Health Sciences 
Education and Training Command will sponsor the fol- 
lowing continuing education courses for Navy nurses: 

Management: Human Relations Performance Evalua- 
tion (24 contact hours) 

25-28 Sept 1977 Bethesda, Md. 

3-6 Oct 1977 Camp Pendleton, Calif. 

This workshop will help supervisors understand why 
people behave the way they do and how to manage 
feelings, attitudes, and reactions of others. Principles 
of performance evaluation will be presented, as well as 

Volume 68, August 1977 



counseling skills, performance expectations, and anal- 
ysis of performance problems. 

Problem Oriented Records and Nursing Audit 
(18 contact hours) 
19-21 Sept 1977 Bremerton, Wash. 

Participants will learn the components of the problem- 
oriented system and the basic principles of problem- 
oriented medical records and audit. Practice will be 
given in developing problem lists, writing progress 
notes in the 'SOAP' format, and applying principles of 
audit using the problem-oriented system. 

Diabetes in Perspective (18 contact hours) 
14-16 Nov 1977 Memphis, Tenn. 

The conference is designed for nurses who want to up- 
date their knowledge on diabetes. Nurses will also de- 
velop teaching plans to prepare diabetic patients to take 
a greater part in their own health care. 

The courses are open to Nurse Corps officers not cur- 
rently assigned to an oversea billet. However, nurses 
assigned to Argentia, Newfoundland; Bermuda; Guan- 
tanamo Bay, Cuba; Keflavik, Iceland; and Roosevelt 
Roads, Puerto Rico, who have served at least six 
months on active duty may apply. The courses are also 
open to Nurse Corps officers of the inactive Reserve on 
a space-available basis. 

Nurse Corps officers wishing to attend these courses 
should apply to the Naval Health Sciences Education 
and Training Command (Code 7), National Naval Medi- 
cal Center, Bethesda, Md. 20014, following procedures 
set forth in the BUMED Instruction 1520.8 series. Ap- 
plications should be submitted several weeks before a 
course begins. 

PUBLIC HEALTH SERVICE OFFERS 
MEDICAL SEMINARS 

The U.S. Public Health Service Hospital at Carville, 
La., will offer the following medical seminars during 

1977-1978: 



Hansen's Disease 



Management of Insensitive Feet 



4-5 Oct 1977 

7-8 Mar 1978 

9-10 May 1978 

18-20 Oct 1977 
14-16 Feb 1978 



For details and registration information, write: Chief, 
Training Branch, U.S. Public Health Service Hospital, 
Carville, La. 70721. Or phone (Area code 504) 642-7771. 



11 



Safety Tips 



Preventing Respiratory Therapy Hazards 



CDR John P. Swope, MC, USN 
BUMED Code 416 

Respiratory therapy is an allied health specialty used 
under medical direction to treat, manage, control and 
evaluate patients with deficiencies and abnormalities of 
the cardiopulmonary system. Respiratory therapy in- 
cludes the use of medical gases and apparatus to 
administer these gases, environmental control systems, 
humidification, aerosols, medications, ventilatory sup- 
port, bronchial pulmonary drainage, pulmonary reha- 
bilitation, cardiopulmonary resuscitation, and airway 
management. 

The National Fire Protection Association Standard 
for Respiratory Therapy (NFPA 56B), which governs 
the use of respiratory therapy equipment and medica- 
tions, was revised in 1976. The revised standard applies 
to all facilities where respiratory therapy and resuscita- 
tion procedures are administered, and covers the use of 
nonflammable medical gases, vapors, and aerosols as 
well as the equipment used to administer these sub- 
stances at normal atmospheric pressure. The standard 
does not apply to areas using special atmospheres, such 
as hyperbaric chambers. 

NFPA 56B offers guidance for protecting patients 
and hospital personnel against hazards associated with 
respiratory therapy: fire, chemical reactions, electric- 
ity, and mechanical hazards associated with gas storage 
devices. 

Fire hazards: For fire to occur, combustible or flam- 
mable materials, oxygen or other oxidizing agents, and 
a source of ignition must be present. Combustible 
materials not normally considered hazardous may be- 
come hazardous as the amount of oxygen in the atmos- 
phere increases. Examples of combustible materials 
often found near patients include hair oils, oil-based 
lubricants, skin lotions, facial tissue, oxygen, bed linen, 
tent canopies, rubber and plastic articles, gas supply 
and suction tubing, and chemicals. 

A particular hazard exists when high-pressure 
oxygen equipment becomes contaminated with grease, 
oil, or other combustibles. Such contaminants ignite 
readily and burn rapidly in high concentrations of 
oxygen; under these conditions, even less combustible 
materials are quicker to ignite. 

Sources of ignition include open flames, sparking 
toys, radiant heaters, or cigarettes being smoked in 
oxygen tents. The discharge of a cardiac defibrillator 



12 



may also be an ignition source. (The literature contains 
several reports of patients being severely burned when 
the discharge of a cardiac defibrillator ignited the com- 
bustible vapor formed when alcohol fumes mixed with 
oxygen used in the patient's therapy.) Electrical equip- 
ment such as razors, bed controls, hair dryers, remote 
TV controls, and telephones may be a source of ignition 
in an oxygen-rich atmosphere. 

Chemical hazards: Residual sterilizing agents in 
high-pressure equipment may create chemical hazards. 
Also, some breathing mixtures, when they contact hot 
surfaces, may decompose and produce toxic or flam- 
mable substances. 

Mechanical hazards: Primary mechanical hazards are 
associated with improper handling of heavy, bulky com- 
pressed gas cylinders. For example, storing cylinders 
outdoors or in unheated ventilated rooms may create 
hazards: when the tanks are chilled, the pressure inside 
drops; then when the cylinder is reheated, the pressure 
may exceed the cylinder's limits and the cylinder may 
rupture. To ensure safety, cylinders should be main- 
tained at a constant temperature. 

Also, cylinders should be stored so securely that they 
cannot tip over. Safety features such as valves and con- 
nections should not be altered or bypassed. 

NFPA 56B specifically prohibits mixing gases or 
transfilling one gas cylinder with the contents from 
another cylinder. This prohibition guards against 
incidents such as the one that occurred when oxygen 
was transfilled into a cyclopropane tank by mistake 
during a surgical operation; this extremely explosive 
mixture detonated, killing four people and injuring 
several others. 

Electrical hazards: In addition to the hazards, men- 
tioned above, of electricity in the ignition of fires, elec- 
trical shock hazards may be associated with defective 
equipment. When nebulized liquids are used in patient 
care, there is a conductive pathway between the patient 
and the electrical equipment which may cause the 
patient to be included in an electrical circuit, with con- 
sequent electrical shock. 

One section of NFPA 56B, entitled "Equipment," 
lists various requirements users of gases must meet; 
for the most part, these requirements are based on 
other cited standards. For example, in the "Gas 

U.S. Navy Medicine 



Supply" subsection, users are directed to conform with 
the 1974 NFPA Standard for Nonflammable Medical 
Gas Systems (NFPA 56F). 

Construction and testing of gas cylinders fall under 
the jurisdiction of the U.S. Transportation, Specifica- 
tions and Regulations. 

Commercial Standard 223-59, "Casters, Wheels, and 
Glides for Hospital Equipment," directs that oxygen 
tents which rest on the floor, and other such apparatus 
used in administration of oxygen, must be so designed 
that the entire apparatus is stable during storage, 
transportation, and use. Copies of Commercial Stand- 
ard 223-59 are available from the Superintendent of 
Documents, U.S. Government Printing Office, Wash- 
ington, D.C. 20402. 

Oxygen tent canopies that have flexible components 
must be made of materials with a maximum burning 
rate classification of "slow burning." Burning rate 
classifications are set forth in Underwriters Laboratory 
Subject 94, "Burning Tests of Plastic." 

Equipment designed for use with high-pressure gas 
cylinders must either be capable of service at full 
cylinder pressure, or must be equipped with or con- 
structed for use with a pressure-reducing regulator. 

NFPA 56B specifies that liquid containers and reser- 
voir jars— such as jars used to hold medicines— shall be 
made of transparent material that does not react with 
the solutions contained in the jars. 

Humidifiers and nebulizers must be equipped with 
an overpressure relief valve or an alarm that will sound 
when the flow of gas is obstructed. 

Gas supply connections— including the pin-index 
safety system for medical gases— are covered by the 
American National Standards Institute (ANSI) Standard 
for Compressed Gas, Compressed Gas Cylinders, Valve 
Outlets and Inlet Connections (B57.1). When low- 
pressure connections of the threaded screw system are 
used, the connections must comply with standards set 
forth in the Compressed Gas Association's pamphlet 
V-5, "Diameter Index Safety System." Low-pressure 
coupler connections shall be noninterchangeable for 
different gases. Regulators and gauges used for high- 
pressure service shall be listed by Underwriters Labo- 
ratory or Factory Mutual as acceptable for such service; 
pressure-reducing regulators shall be appropriate to 
the pressure applied to the system. 

Electrical equipment used in respiratory therapy 
shall comply with the appropriate articles of NFPA 70 
(issued in 1975), which is the National Electrical Code. 
Electrical equipment used in an oxygen-rich atmos- 
phere shall be listed for such use by Underwriters 
Laboratory or Factory Mutual; unlisted equipment shall 
not be used in an oxygen-rich atmosphere. 

EQUIPMENT, APPARATUS, WIRING 

Equipment, apparatus, and wiring used in anesthe- 
tizing locations during respiratory therapy shall comply 



with the 1973 Standard for the Use of Inhalation Anes- 
thetics (NFPA 56A). The "Equipment" section of this 
standard directs that cylinder carts shall be self-sup- 
porting, with enough chains or stays to firmly retain the 
cylinders. One of the hazards of handling cylinders is 
that the cylinder necks can be ruptured, with a 
resulting powerful efflux of compressed gas. The jet 
action effect of this efflux is so strong that in one 
incident the cylinder was propelled through two cement 
walls, struck the rear of an automobile, passed through 
the automobile's body, and pushed the engine out the 
front. Another hazard is that rupture can cause the 
cylinder to spin wildly, endangering nearby people and 
equipment. 

All equipment used with oxygen must be labeled to 
inform patients and health care personnel that oxygen 
is being used and safety precautions must be observed. 

ADMINISTRATION AND MAINTENANCE 

The section of NFPA 56B that deals with administra- 
tion of oxygen during respiratory therapy lists the cor- 
rective or preventive action that must be taken to avoid 
the hazards described above. 

APPENDIX 

The appendix to NFPA 56B includes a wealth of im- 
portant information. Subjects discussed include safe 
handling of equipment, and procedures to follow if a 
fire occurs. 



Instructions and Directives 

Investigation of aircraft accidents 

Before postmortem examinations of aircraft accident 
victims, flight surgeons shall give pathologists com- 
plete information on circumstances of the accident, 
aircraft design, life support and protective equipment 
stored on the plane, and medical histories of accident 
victims. Autopsy protocols should include results of 
external, microscopic and radiographic examinations, 
as well as appropriate photographs and reports of 
toxicologic studies. Reports of postmortem examina- 
tions must be prepared on DD Form 1322. Also, SF 503 
(Clinical Record- Autopsy Protocol) should be used to 
report ancillary data such as microscopic examinations, 
and DD Form 1323 to report results of toxicologic 
examinations. Completed reports of postmortem exam- 
inations shall be submitted to the investigating flight 
surgeon within 10 working days after remains are 
received. Pathologic materials and copies of all reports 
must be submitted to the Director, Armed Forces 
Institute of Pathology. 

Commanding officers of Navy medical facilities shall 
provide any support needed by aircraft accident inves- 
tigators.— BUMED Notice 6510 of 14 April 1977. 



Volume 68, August 1977 



13 



Disposition of rehabilitated alcoholic 
flight personnel 

Flight personnel who are receiving Antabuse therapy 
for alcoholism are disqualified for duty involving flight 
operations if they are directly involved in flying or air 
safety. Such personnel include naval aviators, naval 
flight officers, flight engineers, navigators, communi- 
cators, and air traffic controllers. However, BUMED 
may authorize flying duty for rehabilitated alcoholic 
personnel whose jobs are "mission essential," such as 
sensor station operators and flight attendants; requests 
for the authorization should be submitted via the chain 
of command to BUMED Code 5111. 

Rehabilitated alcoholic aircrew personnel and air 
controllers shall have complete aviation physical exami- 
nations every three months during the first year after 
they return to duty from an alcohol rehabilitation cen- 
ter. These examinations, to be recorded on Standard 
Form 88, shall include the flight surgeon's evaluation of 
the patient's ability to maintain sobriety. The SF 88 
shall be forwarded to BUMED Code 5111 for review 
when the patient is released from inpatient treatment, 
returns to aircrew or air controller duties, returns to 
service group I, II, or III, or is restricted from special 
duty for alcohol-related reasons. Internal medicine and 
psychiatric evaluations shall be sent to BUMED when 
the patient returns to flying or air control duties, or is 
restricted from a special duty assignment for alcohol- 
related reasons. 

Class 1 personnel, when physically qualified, will be 
returned to service group III status for 3 to 12 months. 
After that, they may be returned to unrestricted flying. 
In very carefully considered circumstances, pilots may 
be returned directly to solo pilot status. — BUMED In- 
struction 5300. 4 A of 19 April 1977. 



Recovery room record 

A new form, NAVMED 6320/16, has been developed 
for use in all naval medical facilities to provide a com- 
prehensive record of the treatment patients receive in 
the postanesthesia recovery room. Forms developed 
locally to record this information shall no longer be 
used. 

The Joint Commission on the Accreditation of Hospi- 
tals requires that the Anesthesiologist/Nursing Notes 
section of the new form include the anesthesiologist's 
notes about the presence or absence of anesthesia- 
related complications, and periodic descriptions of the 
patient's condition and changes in level of conscious- 
ness. Only an anesthesiologist should release the pa- 
tient from the recovery room, unless it is the hospital's 
written policy that other physicians or nurse anesthe- 
tists may release patients. 

When the patient leaves the recovery room, the 
NAVMED 6320/16 is to be placed in the clinical 
records. 



Medical Department personnel who use NAVMED 
6320/16 may send their comments and recommenda- 
tions about this new form to BUMED, Code 
721.— BUMED Notice 6320 of 26 April 1977. 

Aviation Pathology Program 

The site and wreckage of fatal aircraft accidents 
should be examined by a pathologist as soon after the 
accident as possible. This investigation should include: 

• Review of medical records of crewmember fatalities, 
to determine medical history and results of physical 
examinations. 

• Review of medical, social, physiological and psycho- 
logical events associated with crewmember fatalities. 

• Examination and photographs of the clothed body of 
fatalities, with personal equipment intact. 

• Radiographs and photographs of unclothed body. 

• Gross and microscopic autopsy. 

• Special studies of tissues and body fluids. 

• Analysis of all pertinent evidence. 

• Final report. 

The investigation cannot be considered complete 
without an autopsy of each crewmember fatality — 
preferably performed by a pathologist trained in avia- 
tion or forensic pathology. This autopsy is unique in 
that the investigator is concerned with establishing or 
ruling out pathological processes as causative or 
contributory factors in every aircraft accident. As a 
member of the accident investigation team, the pathol- 
ogist seeks to establish the relationship between pre- 
existing disease and the accident, to correlate injuries 
with factors in aircraft and equipment design, and to 
study pathological evidence to determine the sequence 
of events surrounding the accident. 

The medical accident investigator shall inform com- 
manding officers, civil authorities, and others in a posi- 
tion to authorize an autopsy of the need for the proce- 
dure. A flight surgeon shall assist at the autopsy to 
ensure that the maximum aeromedical information is 
obtained. Flight surgeons who find they must perform 
the autopsy themselves may use NAVMED P-5065, 
Autopsy Manual, as a guide. 

Pathological investigations shall be conducted even 
when remains are fragmentary or dispersed. Tissue 
specimens for toxicologic studies may be shipped air 
freight to the Armed Forces Institute of Pathology. Air 
mail must not be used. Detailed instructions for pre- 
paring and mailing autopsy material are given in this 
instruction. 

When a civilian pathologist performs the autopsy, 
charges shall be paid by the Medical Department. Bills 
shall be submitted to BUMED Code 73 through the 
naval activity authorizing the civilian physician's ser- 
vices. 

The tri-service regulation on the Joint Committee of 
Aviation Pathology is an enclosure to this instruction. — 
BUMED Instruction 6510.6B of 11 May 1977. 



14 



U.S. Navy Medicine 



Scholars' Scuttlebutt 



Graduate Medical Education 
Program Directors 

Three changes have been made in the list of graduate 
medical education program directors published in the 
May 1977 issue of US Navy Medicine. This is the up-to- 
date list: 



CDR R. Higgins, MC, U5N 

Naval Regional Medical Center 
Charleston, S.C. 29403 

CDR S.A. Borel, MC, USN 
Naval Regional Medical Center 
Camp Pendleton, Calif. 92055 

CAPT C.L. Gaudry, Jr., MC, USN 

Naval Regional Medical Center 
Jacksonville, Fla. 32214 

CDR E.L. Taylor, MC, USN 

Naval Aerospace and Regional Medical Center 
Pensacola, Fla. 32512 

CAPT D.R. Cordray, MC, USN 
Naval Regional Medical Center 
Portsmouth, Va. 23708 

CDR Walter V.R. Vieweg, MC, USN 
Naval Regional Medical Center 
San Diego, Calif. 92134 

CDR D.M. Robinson, MC, USN 
Naval Regional Medicjl Center 
Oakland, Calif. 94627 

CAPT Q.E. Crews, Jr., MC, USN 
National Naval Medical Center 
Bethesda, Md. 20014 



At the Naval Health Sciences Education and Training Command: 

CDR C.T. Cloutier, MC, USN 

HSETC Code 4 

Bethesda, Md. 20014 Phone: (202) 295-0648 

At Bureau of Medicine and Surgery: 

CAPT Stanley J. Kreider, MC, USN 

BUMED Code 0011 

Washington, D.C. 20372 Phone: (202) 254-4279 

CDR Clarence B. Mohler, MSC, USN (Ret.) 
BUMED Code 314 Phone: (202) 254-4339 



Will You Get the 
Internship You Want? 

Navy-sponsored medical students planning to begin 
their internship next July often ask us, "What are my 
chances of getting the internship of my choice?" 

Here's how the results shaped up for students who 
began their internship in July this year: 

194 got their first specialty choice. 

10 got their second specialty choice. 

3 got their third specialty choice. 

175 were assigned to their first choice of naval re- 
gional medical center. 

23 were assigned to their second NRMC choice. 

9 were assigned to their third NRMC choice. 

The chart below shows the number of internship 
positions offered at naval regional medical centers this 
year, and the students' preferences for these intern- 
ships. 

Another 24 candidates were selected from the fleet 
for first-year level programs. These officers are not in- 
cluded in the chart or in the numbers given above. 



Candidate Preference for Internships to Begin 1 July 1977 







Medicine 


Surgery 




OB/GYN 


Pathology 




Pediatrics 


Psychiatry 




A 


BCD A 


B 


C 


D 


A B C D 


A B C D 


A 


BCD 


A B C D 


Bethesda 


21 


35 21 31 13 


21 


11 


15 


3 7 2 8 


3 6-3 


3 


5 3 10 


4 14 1 


Oakland 


17 


20 24 20 13 


12 


21 


10 


3 5 11 6 


2 2 4 1 


3 


8 7 9 


3 5 11 


Portsmouth 


18 


16 23 19 13 


16 


14 


13 


6 3 5 4 


d. lL \J *j 


5 


9 7 4 


4 114 


San Diego 


32 


43 31 26 16 

Family Practice 
A B C D 


20 


18 


21 


4 12 8 4 


3 2 3 3 


5 


10 13 4 




Camp Pendleton 


9 10 5 5 




Key 


A = 


number of positions offered 








Charleston 




9 18 24 8 






B = 


number of candidates listing that program as first choice 


Jacksonville 




9 16 15 22 






C = 


number of candidates listing that 


program as second choice 


Pensacola 




8 14 13 20 






D = 


number of candidates listing that program as third choice 



Volume 68, August 1977 



15 



On Duty 

A Medical Officer Deploys to the Indian Ocean 



LCDR Kenneth L. Andrus, MC, USNR 



From July 1976 through March 
1977, I served as medical officer on 
board the USS Truxtun (CGN-35) 
during an eight-month deployment 
to the Western Pacific. Besides 
visits to Subic Bay, Hong Kong, 
Wellington (New Zealand) and Mel- 
bourne (Australia), our cruise in- 
cluded two Indian Ocean excur- 
sions. This projection of U.S. naval 
power into the Indian Ocean pre- 
sented Truxtun's medical depart- 
ment with some unique problems in 
operational medicine. 

Far from help. In the Indian 
Ocean area, I was immediately im- 
pressed by the lack of medical facil- 
ities and the prohibitive distances 
from our ship to the nearest supply 
points and hospitals. In such situa- 
tions, medical officers must rely on 
vigorous preventive medical and 
dental programs, and acquire a 
thorough knowledge of available 
medical resources. Prior planning is 
essential, and I found the informa- 
tion in the CINCPACFLT port 
guide, as well as discussions with 
medical officers who had been in 
the Indian Ocean, invaluable in 
preparing for the cruise. In planning 
for Indian Ocean tours, medical of- 
ficers should be prepared to give 
medical assistance to other ships in 
the area, as I did for the USNS 
Wilkes and a British supertanker 
when personnel aboard those ships 
were injured. 

Even if you are prepared, you can 
still be startled by what you find on 



LCDR Andrus was the medical officer of 
the USS Truxtun from June 1976 through 
June 1977. He is now serving a residency in 
internal medicine at Naval Regional Medical 
Center Portsmouth, Va. 23708. 



a port call, as I was when we visited 
Karachi, Pakistan, and Port Victoria 
in the Seychelles Islands. 

Karachi, the major port city of 
Pakistan, was a stop on our first 
Indian Ocean excursion. The city's 
population has swollen to more than 
6 million in the past few years. 
Public services have not kept pace 
with this growth, so health and sani- 
tary conditions have suffered. The 
problems we encountered in Kara- 
chi are representative of those seen 
in many Indian Ocean ports: dis- 
eases endemic to the city include 
rabies, trachoma, ascariasis, hook- 
worm, malaria, hepatitis, polio, 
amebic and bacillary dysentery, and 
venereal disease. 

Before liberty in Karachi, I 
mounted an intensive education 
program to heighten crewmembers' 
awareness of potential health prob- 



lems. Nevertheless, many men 
became ill even after they had exer- 
cised extreme caution ashore. Ame- 
bic and bacillary dysentery were 
rampant among the people of 
Karachi, and 60 of our men con- 
tracted one of these diseases. One 
man acquired a hookworm infec- 
tion, another required rabies vac- 
cinations after he was bitten by a 
monkey. 

Plan ahead. The big lesson I 
learned from our experience in 
Karachi was that to ensure ade- 
quate treatment of the crew on an 
Indian Ocean deployment, certain 
medical supplies should be ordered 
well in advance: chloroquine, pri- 
maquine, at least two full series of 
DEV (duck embryo vaccine) rabies 
vaccine, and at least 250 tablets of 
metronidazole for every 100 men. 
Since metronidazole is so expen- 




USS Truxtun, a nuclear-powered guided missile frigate, en route to Indian Ocean 



16 



U.S. Navy Medicine 



sive, medical officers may want to 
substitute diiodohydroxyquin for 
treating Entamoeba histolytica. I 
found that BUMED Instruction 
6230. 11G provided valuable infor- 
mation on supplies we would need 
for our malaria prophylaxis pro- 
gram. I also learned the wisdom of 
stocking enough Lomotil, Donnatal, 
Kaopectate, and Combid to allow 
for treating at least 20% of the 
crew. 

On Truxtun we distilled our own 
water rather than use water of 
dubious safety from water barges. 
Although distillation alone is con- 
sidered cysticidal, our water supply 
had to be chlorinated and main- 
tained at a level of 3 mg to 5 mg 
chlorine per liter of water to ensure 
potability. This chlorination proce- 
dure requires tremendous quanti- 
ties of calcium hypochloride, which 
must be ordered in advance. 

Although we were leery of buying 
any food in Karachi, we found a 
reputable local ship's chandler who 
sold us fruits and vegetables. After 
the food was inspected thoroughly, 
it was brought on board and con- 
sumed with no ill effects. 

An interesting entomological 
phenomenon occurred while we 
were at anchor six miles from shore: 
we were invaded by a horde of 
flying insects attracted by our 
lights. For several days, we had to 
endure flying grasshoppers every- 
where! 

Task force. When Truxtun de- 
ployed to the Indian Ocean for the 
second time, we were part of a 
nuclear-powered task force which 
included the USS Enterprise, USS 
Long Beach, and USS Tautog. Be- 
cause these ships are largely self- 
sufficient, we spent only four days 
in port during the eight-week de- 
ployment. 

Long periods at sea, combined 
with a lack of "good" liberty ports 
and erratic mail service, were hard 
on the crew, so we were fortunate in 
being able to visit the Seychelles 
Islands. This is a new country com- 
prising some 96 islands northeast of 
Madagascar. Mahe Island, on which 
Port Victoria is located, reminded 



us of the Caribbean. We had a re- 
laxing stay, sharing the harbor with 
a French destroyer. Unfortunately, 
my high school French failed me 
completely at a reception given for 
us by the French ship. 

The one Government-run hospi- 
tal, with its open wards around a 
central courtyard, reminded me of a 
hospital I had seen in a movie about 
French Equatorial Africa. The Sey- 
chelles facility was operated by 
British-trained physicians who, al- 
though overworked, provided good 
care to their patients. The food, 
while good, was delivered haphaz- 
ardly by the chandlers and was ter- 
ribly expensive, since much of it is 
imported from South Africa. 

Health conditions on the Islands 
were quite good, but an unusual 
medical problem took us by sur- 
prise. During Truxtun 's visit, local 
health officials expressed concern 
over an outbreak of a new illness 
that resembled dengue fever. Thus 
forewarned, I was prepared for the 
baffling set of symptoms I saw in 
five crewm embers who abruptly 
presented with fevers as high as 
103 °F, malaise, myalgia, flank pain, 
retro-orbital headache, and ocular 
pain, especially on lateral gaze. Our 
men, who were not affected as seri- 
ously as were the islanders, im- 
proved after only conservative ther- 
apy. Acute and convalescent sera 
we collected were sent to Environ- 
mental and Preventive Medicine 
Unit No. 5 in San Diego for 
serological analysis, while COM- 
NAVSURFPAC and EPMU-7 in 
Naples provided guidance and as- 
sistance after we filed a disease 
alert report. (Although we ordinar- 
ily could have called on EPMU-6 in 
Subic Bay for assistance, EPMU-7 
in Naples was closer.) 

Medevacs. Depending on where 
we were operating, our patients 
could have been aeromedically 
evacuated via Diego Garcia to Naval 
Hospital Subic Bay, to Naval Re- 
gional Medical Center Naples, or to 
an Army hospital in Frankfurt, Ger- 
many. I quickly found that it was 
advisable to keep tabs on what 
Indian Ocean ports had hospitals 




A familiar sight in Karachi, Pakistan 

which could handle problems be- 
yond the capabilities of my depart- 
ment. One of our men with sus- 
pected obstructive liver disease was 
aeromedically evacuated from Ka- 
rachi to Naval Hospital Subic Bay 
for observation and treatment. Op- 
erating with the nuclear-powered 
task force proved to be advanta- 
geous because in areas where medi- 
cal facilities were lacking and aero- 
medical evacuation difficult, the 
hospital and surgical capabilities of 
the Enterprise were invaluable. 

I left the Indian Ocean with a 
number of observations. Medical 
support, although often far away, 
was still accessible. A continuing 
awareness of potential health prob- 
lems and sources of assistance was 
essential. Finally, special attention 
must be paid to long-range planning 
for medical supplies, to ensure that 
adequate amounts of necessary 
supplies are aboard and that ade- 
quate lead time is allowed for their 
delivery. 

For those Navy medical personnel 
who venture into the Indian Ocean, 
its ports provide fascinating visits 
and a chance to practice a chal- 
lenging type of operational medi- 
cine. 



Volume 68, August 1977 



17 



Features 



Use of Inpatient Adjunct Services 
in Naval Hospitals 

LCDR R.A. Payton, MSC, USN LT W.L. Roach, Jr., MSC, USN 



Because of increased emphasis 
on improving the cost effectiveness 
of medical care through utilization 
reviews, hospitals are establishing 
programs of admission certification, 
continued stay review, and ancillary 
service utilization review. The goal 
of such programs is to ensure that 
patients receive services appropri- 
ate for treatment of their illnesses. 
Under Professional Standards Re- 
view Organization (PSRO) legisla- 
tion, hospitals must inform federal 
and state agencies of the diagnoses 
of patients who are beneficiaries of 
Medicare, Medicaid, and maternal 
and child health programs, and of 
the ancillary services provided to 
these patients. Payments for unjus- 
tified ancillary services which ex- 
ceed PSRO criteria for a particular 
diagnosis may be denied. 

EFFECT OF HOSPITAL SIZE 

The range of ancillary services 
provided to hospitalized patients is 
wide. Patients in the same hospital 
with the same diagnosis do not al- 
ways receive the same number and 
type of ancillary services. Many 
variables affect the physician's 
decision to use a specific diagnostic 
or therapeutic service in a patient's 
therapy. 

What effect does the size of the 
medical treatment facility have on 
the volume of service provided to 

LCDR Payton is director of the Research 
Division, Naval School of Health Care Ad- 
ministration, National Naval Medical Center, 
Bethesda, Md. 20014. LT Roach is a member 
of the School's faculty. 




1976 



Lab 


73% 


Pharmacy 


19% 


X-ray 


6% 


Other 


2% 



other 

ECG 

EEG 
Radioisotope 

therapy 
Audiograms 



Figure 1. Composition of inpatient adjunct services provided by naval medical 
centers and hospitals in CONUS, 1976. (1) 



patients? We have analyzed the 
number of adjunct services received 
by inpatients in selected naval hos- 
pitals in the continental United 
States (CONUS) to determine varia- 
tion among hospitals of different 
sizes. The effect of hospital size on 
the volume of adjunct services can 
be seen by determining the amount 
of inpatient adjunct services* pro- 
vided for each admission. 

In shore-based naval inpatient 
medical facilities, more than 98% of 
inpatient adjunct services fall in one 
of three categories: laboratory tests, 
X-ray film exposures and pharmacy 
units (1). Over a short term, from 
1973 to 1976, the mix of services 
provided in naval medical centers 
and hospitals in CONUS remained 



The Navy Medical Department defines in- 
patient adjunct services as laboratory tests, 
pharmacy units, pulmonary function studies, 
X-ray film exposures, audiograms, dialysis 
procedures, electrocardiograms, electroen- 
cephalograms, radioisotope studies, fluoro- 
scopic exams, and radium and radioisotope 
therapy. 



relatively constant, while the vol- 
ume of services rendered increased 
from 14.7 million (2) to more than 
18.7 million (J). Figure 1 illustrates 
the percent of adjunct services pro- 
vided to inpatients in naval medical 
facilities in 1976. 

Based on FY76 data, we stratified 
selected naval medical facilities in 
CONUS by average daily patient 
load (ADPL) into four classes: 400 
or greater ADPL, 200-399 ADPL, 
100-199 ADPL, and ADPL less than 
100 (see Table). The average num- 
ber of inpatient adjunct services per 
admission (total inpatient adjunct 
services divided by the total number 
of admissions) for the naval medical 
facilities we analyzed for FY76 was 
93. As shown in Figure 2, the larger 
medical centers clearly provide 
more adjunct services for each pa- 
tient admitted. In fact, in 1976 in- 
patients in the "more than 400" 
facilities used 44% more services 
than the overall average for each 
admission, and 153% more services 
than inpatients admitted to facilities 



18 



U.S. Navy Medicine 



in the 100-199 ADPL category. It 
must be noted that all facilities in 
the "more than 400" group have 
postgraduate medical education 
programs and are core hospitals of 
large naval medical regions; the 
large number of ancillary services 
used in these hospitals is partly 
attributable to the "teaching ef- 
fect' ' and to the large proportion of 
patients with complex diagnoses 
who tend to require more adjunct 
services. 

Noteworthy, too, was the increase 
from 1973 to 1976 in the amount of 
adjunct services provided for each 
admission. The increased rate of 
service for "more than 400" facili- 
ties — 33% — paralleled the average 
overall increase of 33%. The con- 
stant annual increase in inpatient 
services for all categories amounted 
to 9.9% from 1973 to 1976. In one 
naval medical treatment facility in 
the 200-399 ADPL category, the 
number of admissions for 1976 was 
30% less than in 1973, while the 
number of adjunct services was 
38 % higher for the same two years 
(5,8). For all facilities studied, the 
number of inpatient adjunct ser- 
vices was 37% higher in 1976 than 
in 1973, while the number of admis- 
sions increased only 2 % during the 
same period (5,8). 

The American Hospital Associa- 
tion, in its analysis of civilian medi- 
cal facilities, reported a general 
correlation between hospital size 
and distribution of most services: as 
hospital size increased, so did the 
likelihood that the hospital would 
offer a particular service (9). This 
correlation was strongest for ser- 
vices that require complex equip- 
ment, a large capital investment, 
and highly skilled technicians. 

LABORATORY TESTS 

The growth of medical technology 
has given the physician increasingly 
varied types of laboratory proce- 
dures. Can we reduce the number 
and type of laboratory tests used in 
our hospitals but still provide the 
physician with enough tools to make 
sound medical decisions? A recent 



TABLE. Inpatient Adjunct Services Per Admission in Selected 
Naval Medical Centers and Hospitals, 1973-1976 





Average Daily 










Facility 


Patient Load 


Inpatient Adjunct Services /Ad mission 




(ADPL) 


i 










1976° 


1973 b 


1974 e 


1975 d 


1976° 


Over 400 ADPL 












NRMC San Diego 


766 


95 


107 


108 


99 


NRMC Portsmouth 


578 


98 


117 


118 


152 


NNMC Bethesda 


468 


138 


123 


156 


191 


NRMC Philadelphia 


415 


81 


90 


105 


146 




Average 


101 


110 


118 


134 


200-399 ADPL 












NRMC Oakland 


352 


90 


86 


75 


74 


NRMC Camp Pendleton 


245 


47 


49 


56 


75 


NRMC Camp Lejeune 


224 


43 


48 


43 


48 


NRMC Long Beach 


212 


74 


94 


87 


100 


NRMC Great Lakes 


203 


54 


76 


120 


120 




Average 


63 


71 


73 


80 


100-199 ADR. 












NRMC Jacksonville 


194 


59 


64 


93 


80 


NRMC Charleston 


169 


61 


51 


66 


53 


NARMC Pensacola 


126 


51 


62 


70 


74 


NH Orlando 


117 


30 


36 


30 


31 


NH Beaufort 


100 


21 


25 


22 


22 




Average 


44 


48 


55 


53 


Less than 100 ADPL 












NRMC Bremerton 


95 


29 


45 


42 


42 


NH Memphis 


83 


46 


44 


69 


76 


NRMC Newport 


68 


37 


47 


86 


70 


NH Corpus Christ i 


58 


34 


42 


65 


66 


NSMC New London 


56 


34 


47 


59 


83 


NH Quantico 


42 


32 


34 


26 


20 


NH Key West 


29 


43 


45 


48 


45 


NH Annapolis 


26 


35 


33 


40 


34 


NH Patuxent River 


16 


29 


20 


24 


38 




Average 


36 


41 


49 


55 




Overall average 


70 


78 


84 


93 



a. Statistics of Navy Medicine, NAVMED P-5028, Vol. 32, No. 4, 1976. 

b. Statistics of Navy Medicine, NAVMED P-5028, Vol. 29, No. 4, 1973. 

c. Statistics of Navy Medicine, NAVMED P-5028, Vol. 30, No. 4, 1974. 

d. Statistics of Navy Medicine, NAVMED P-5028, Vol. 31, No. 4, 1975. 



Volume 68, August 1977 



19 



Ad J unct 

Services 

Per 

Admission 



130 

120 

110 

100 

90 

80 

70 

60 

50 

40 

30 









•S 








































-* 


















_ _, ,_. 


,--"' 






^ r J*-* r 












*•* 








, — -"" 


:>- 








-•"■*""" 









More than 400 ADPL 



Overall Average 
200-399 ADPL . 



Less than 100 ADPL -- 
100-199 ADPL 

Hospital Size in 
Average Daily 
Patient Load 
(ADPL) 



FY 1973 



•74 



'75 



'76 



Figure 2. Inpatient adjunct services per admission in selected naval medical cen- 
ters and hospitals In CONUS. (5-8) 



study performed in Canadian hos- 
pitals (10) revealed that when con- 
straints were imposed on ordering 
laboratory tests, practicing physi- 
cians showed a greater tendency 
than house staff members (clinical 
clerks and residents) to disregard 
tests, depending instead on their 
previous experience and on the 
physical examination of the patient. 
The researchers found that house 
staff physicians frequently ordered 
more tests as a measure of caution, 
since there were abundant labora- 
tory facilities. When constraints 
were introduced, both practicing 
physicians and house staff members 
took more risks in reducing screen- 
ing measures and tests for second- 
ary diagnoses. Further, it appeared 
that under the pressures of limited 
test ordering, both residents and 
seasoned physicians discarded tests 
required for hospital accreditation, 
such as urinalyses and hemoglobin 
counts. Despite benefits gained 
from the reduced demand for ser- 
vices, however, the study advocated 
a cautious approach to limiting 
laboratory use, to avoid any nega- 
tive impact on physician efficiency. 
Statistics from the American Hos- 
pital Association's Hospital Admin- 
istrative Services section show that 
larger hospitals provide more clini- 
cal laboratory services than smaller 



hospitals, but that the cost per test 
is less in larger hospitals than in 
smaller hospitals (//). This lower 
cost may be due in part to the de- 
gree of automation in clinical labo- 
ratories of larger hospitals. The fact 
that in hospitals with more than 300 
beds fewer tests are performed per 
man-hour than in hospitals with 
under 300 beds suggests that only a 
standard core of tests is automated. 
In larger hospitals, labor productiv- 
ity is decreased by nonroutine tests 
which may require time-consuming, 
sophisticated hand analysis. In- 
creased test complexity partly ac- 
counted for a decrease from 1969 to 
1972 in the number of tests per- 
formed per man-hour in all hospitals 
studied by the AHA (12). 

Hospital medical staffs establish 
the minimum number of laboratory 
and radiographic tests required for 
all patients admitted. Do these re- 
quirements lead to unnecessary 
overuse of laboratory and radiology 
services? How much benefit does 
the patient derive from these re- 
quired tests? Are they valid for all 
patients admitted? Should the ad- 
mitting physician determine which 
and how many tests to order for 
each patient on admission, or 
should the hospital medical staff 
require that certain tests be per- 
formed for every patient on admis- 



sion? Does the hospital know what 
percent of patients receive the mini- 
mum required admission tests? 

Statistics from the Professional 
Activities Study sponsored by the 
Commission on Professional and 
Hospital Activities, Ann Arbor, 
Mich., revealed that in 1975 less 
than half of all inpatients in one 
naval regional medical center were 
receiving the minimum required 
laboratory tests. Analysis of patient 
records revealed that large numbers 
of patients were not receiving a 
VDRL test for syphilis, one of the 
required admission tests. After dis- 
cussing the requirement for this 
particular test and the value of the 
test for pediatric and other selected 
groups of patients, the hospital's 
Quality Assurance Program Com- 
mittee recommended that the VDRL 
test be eliminated as a requirement 
on admission. This is just one in- 
stance in which the use of Profes- 
sional Activity Study statistics 
helped a naval medical staff estab- 
lish better policies and procedures 
to promote quality patient care. 

Preadmission testing programs 
need to be analyzed to obtain infor- 
mation on the number of tests per- 
formed on inpatients before admis- 
sion. In the Navy, tests done before 
admission are recorded as outpa- 
tient tests. In some hospitals, the 
patient mix may allow a greater 
percent of preadmission testing 
than in other hospitals. The availa- 
bility of certain tests and the will- 
ingness of the medical staff to per- 
form some tests on an outpatient 
basis also influence the number of 
outpatient tests performed. 

The ability of hospitals to perform 
ancillary tests on a less costly out- 
patient basis and the use of this 
cheaper form of treatment vary ex- 
tensively among hospitals. For ex- 
ample, recently instituted medical 
holding companies in Navy hos- 
pitals may affect the volume of 
services provided to inpatients; 
clinical studies previously per- 
formed late in a patient's hospitali- 
zation are now being done after 
active-duty inpatients are dis- 
charged to duty in the medical 



20 



U.S. Navy Medicine 



holding company and before they 
return to full duty. This discharge 
reduces the volume of tests per- 
formed on inpatients while increas- 
ing the number of tests performed 
for each outpatient. 

CONCLUSIONS 

Many other questions relating to 
this discussion could be addressed. 
How much of the increase in use of 
ancillary services is attributable to 
physicians practicing "defensive 
medicine" for fear of malpractice 
suits? How much of the increase is 
caused by the "teaching effect"? 
How many tests have been repeated 
because an inexperienced techni- 
cian or student made a mistake? 
What effect does the free cost of 
medical care in military facilities 
have on the use of ancillary services 
there? How many tests are re- 
ordered by physicians because they 
question the accuracy of the initial 
tests, rather than leaving quality 
control to the pathologist? How 
many tests have been reordered be- 
cause the initial results were lost or 
misfiled? 

Inpatient adjunct service statis- 
tics (8) indicate that fewer services 
per admission (44% less than the 
overall average for FY76) are used 
by patients in hospitals primarily 
supporting Marine Corps activities. 
This fact may be attributed to a 
population of less ill active-duty pa- 
tients who may have been admitted 
only to remove them from a work 
environment which may have been 
aggravating their condition. Some 
other level of care might adequately 
meet these patients' needs. Hospi- 
talization of such patients may not 
be the best solution to a problem 
which should be solved by a much 
less costly alternative. 

Empirical studies have not been 
performed in naval medical facilities 
to answer all the questions we have 
posed. Perhaps the questions can- 
not be answered by measuring 
empirical data. An effective utiliza- 
tion review program can give health 
care professionals a viable means to 
control and eliminate unjustified 



medical care. More attention needs 
to be devoted to analyzing perform- 
ance data in naval medical facilities 
— only by looking at performance 
data can we obtain the information 
we need to evaluate the effective- 
ness of medical care. Continued 
analysis and examination of hospital 
performance will highlight problem 
areas. Using positive and innovative 
approaches, we can identify the real 
problems of health care delivery 
and ensure the best use of our re- 
sources. 

REFERENCES 

1 . Statistics of Navy Medicine, NAVMED 
P-S028, Vol. 32, No. 4. Department of the 
Navy, Bureau of Medicine and Surgery, 
1976, p. 24. 

2. Statistics of Navy Medicine, NAVMED 
P-5028, Vol. 29, No. 4. Department of the 
Navy, Bureau of Medicine and Surgery, 
1973, p. 18. 

3. Statistics of Navy Medicine, NAVMED 
P-5028, Vol. 32, No. 4, Department of the 
Navy, Bureau of Medicine and Surgery, 
1976, p. 26. 



4. Statistics of Navy Medicine, NAVMED 
P-5028, Vol. 32, No. 4. Department of the 
Navy, Bureau of Medicine and Surgery, 
1976, p. 18. 

5. Statistics of Navy Medicine, NAVMED 
P-5028, Vol. 29, No. 4. Department of the 
Navy, Bureau of Medicine and Surgery, 

1973, p. 18. 

6. Statistics of Navy Medicine, NAVMED 
P-5028, Vol. 30, No. 4. Department of the 
Navy, Bureau of Medicine and Surgery, 

1974, PP- 18, 32-33. 

7. Statistics of Navy Medicine, NAVMED 
P-5028, Vol. 31, No. 4. Department of the 
Navy, Bureau of Medicine and Surgery, 

1975, pp. 12, 26. 

8. Statistics of Navy Medicine, NAVMED 
P-5028, Vol. 32, No. 4. Department of the 
Navy, Bureau of Medicine and Surgery 

1976, pp. 14, 26. 

9. HAS administrative profiles. Hospi- 
tals (Journal of the American Hospital Asso- 
ciation) 44:32, 16 Dec 1970. 

10. Hardwick DF, et al: Clinical styles and 
motivation: A study of laboratory test use. 
Med Care XIII(5):397-407, May 1975. 

11. HAS administrative profiles. Hospi- 
tals (Journal of the American Hospital Asso- 
ciation) 44:28, 16 June 1970. 

12. HAS administrative profiles. Hospi- 
tals (Journal of the American Hospital Asso- 
ciation) 47:40, 16 June 1973. 



DON'T MISS 



Pulmonary Function Testing in 
Occupational Medicine 



Biological monitoring such as 
spirometry, along with industrial 
hygiene practices, comprises the 
core of any effective occupational 
health endeavor. Now, a new tech- 
nical manual from the Navy Envi- 
ronmental Health Center clarifies 
the essential requirements of a 
practical pulmonary function 
screening program. 

In "Pulmonary Function Testing 
in Occupational Medicine," LCDR 
Edward P. Horvath, Jr. (MC) tells 
how to select and calculate specific 
spirometric tests, and how to inter- 
pret baseline and followup spiro- 
grams. Also discussed are spirome- 
ters and instrument specifications. 

Routine assessment of pulmonary 
function is becoming increasingly 
common in preemployment and 
periodic physical examinations of 
industrial workers. The Navy, for 
example, requires pulmonary func- 



tion studies for workers exposed to 
asbestos, beryllium, and iso- 
cyanates. Combined with a careful 
history and physical examination, 
such preplacement screening can 
identify job applicants who have 
preexisting functional impairment 
or who are unusually susceptible to 
airborne substances. Regular fol- 
lowup studies can help detect respi- 
ratory impairment early enough for 
therapy to be beneficial. 

Properly implemented pulmonary 
function screening programs will 
help fulfill the intent of the Occupa- 
tional Safety and Health Act and 
ensure safe and healthful working 
conditions for the Navy's men and 
women. 

Copies of LCDR Horvath's report 
may be obtained from the Navy 
Environmental Health Center, 3333 
Vine St., Cincinnati, Ohio 45220. 
Ask for Technical Manual 77-1. 



Volume 68, August 1977 



21 



Education & Training 



Teaching Diabetic and Cardiac Patients: 
New Guidelines 



CAPT J.S. Shaw, NC, USN LCDR J.H. Smith, NC, USN 



For the past two years, nursing 
personnel at Naval Regional Medi- 
cal Center Bremerton, Wash., have 
used guidelines developed by LT 
Susan Shumaker, NC, USNR to in- 
struct patients with diabetic or car- 
diac conditions. 

While charge nurse on the medi- 
cal ward, LT Shumaker had found 
that her staff was reluctant to begin 
any instruction of diabetic or cardiac 
patients because they were unsure 
of what kind of instruction or how 
much information the patients 
needed. LT Shumaker faced other 
problems as well: When should the 
instruction begin? How detailed 
should the instruction be? Should 
nurses use ordinary language or 
medical terminology when teaching 
patients about their illness? How 
could the staff resolve inconsist- 
encies between the information 
medical officers gave patients and 
the instructions given by nurses as- 
signed to the unit? 

To overcome the haphazardness 
of the teaching plan then being fol- 
lowed, LT Shumaker compiled two 
manuals: "Myocardial Infarction: 
Guidelines for Teaching Patient and 
Family" and "Diabetes Mellitus: 
Guidelines for Teaching Patient and 
Family." The manuals were ap- 
proved by the chief of the Medical 
Service and members of his medical 
staff. All diabetic and cardiac pa- 



CAPT Shaw is assistant chief of the 
Nursing Service, Naval Regional Medical 
Center Bremerton, Wash. 98314. LCDR 
Smith was formerly educational coordinator 
at NRMC Bremerton and is now studying for 
an M.S. degree in nursing at the University 
of Washington in Seattle. 



■J 2 




LT Susan Shumaker (NC) shows a hos- Acting the role of a diabetic patient, the 
pital corpsman how to help patients hospital corpsman draws up his insulin 
learn to calculate their insulin dosage, dosage following nurse's instructions. 




t -w m —i m "rs.~ n ^ > 

LT Shumaker and hospital corpsman review instructions in the training manual for 
teaching diabetic patients. 

U.S. Navy Medicine 



tients at NRMC Bremerton now 
receive instruction about their ill- 
ness according to the guidelines 
outlined in these manuals. 

The manuals, whose 20 to 30 
pages are assembled in a looseleaf 
notebook, are written in both lay 
and medical terminology. This helps 
the teacher — whether Nurse Corps 
officer, licensed practical nurse, 
hospital corpsman or nursing assist- 
ant — to clearly understand the con- 
tents and to teach patients of vari- 
ous educational levels. In addition 
to illustrations, charts, and dia- 
grams, the manuals include Ameri- 
can Heart Association and Ameri- 
can Diabetic Association literature 
which is given to each patient along 
with the addresses of local re- 
source agencies. 

The guidelines help staff mem- 
bers to: 

• Determine the best time to begin 
teaching the patient; 

• Assess each patient's learning 
needs; 

• Arrange the sequence and 
amount of information to be taught 
each day. 

Once the teaching program be- 
gins, nurses' notes document each 
patient's progress and level of com- 
prehension. Nursing Care Plan II 
(NAVMED 6550/1A) is used to 
record how much information is 
covered in each teaching session. 
Although the nurse alone is respon- 
sible for seeing that all instruction is 
completed and documented before 
the patient's discharge, all staff 
members are encouraged to become 
involved in the program. 

The chief results of these efforts 
are that patients and their families 
obtain clear and relevant informa- 
tion about specific diseases affect- 
ing them, and that the patient's 
understanding of this information is 
monitored. Medical center inter- 
nists are assured that instruction of 
cardiac and diabetic patients begins 
promptly, and are provided daily 
reports on what the patients and 
their families are learning. Follow- 
up home visits by Navy Relief 
nurses become more productive be- 
cause the nurses can reinforce what 

Volume 68, August 1977 



the patients have learned and help 
them adjust to any changes in 
lifestyle caused by their illness. 

Since the guidelines have been 
introduced at NRMC Bremerton, 
nursing staff members have become 
more comfortable with their teach- 
ing assignments and have been 
better able to document the results 
they achieve. Medical and nursing 
audits, too, show considerable im- 
provement in documenting the pa- 
tient's progress, both medically and 
in terms of knowledge and aware- 
ness of the disease. 

The standardized guidelines de- 
veloped by LT Shumaker have been 



made available to nurses through- 
out the region. And the work con- 
tinues. Nurses at NRMC Bremerton 
are studying the possibility of de- 
veloping guidelines for teaching 
patients who suffer from other 
chronic conditions, and for teaching 
new mothers how to care for their 
babies. 

[NOTE: Single copies of univer- 
sally applicable sections of the 
guidelines described in this article 
are available from the Bureau of 
Medicine and Surgery (Code 322) 
upon request by directors of nursing 
services in Navy health care facili- 
ties. Ed.] 



CPR Training at Pax River 



On 30 April, Naval Hospital Pa- 
tuxent River, Md., hosted a cardio- 
pulmonary resuscitation-basic life 
support instructors' course for Navy 
members and local civilians. The 
training, which met requirements of 
the American Heart Association and 
American Red Cross, qualified 13 
new instructors to teach at the 
Naval Air Test Center, Patuxent 
River, and in neighboring com- 
munities. 

Course director LCDR Lou E. Bell 
(NC) of the hospital staff has taught 
CPR instructor courses and basic 
CPR classes for the past two years. 



Her teaching staff includes two 
hospital corpsmen, a Red Cross 
trainer, a high-school teacher, and a 
nurse from a nearby civilian hos- 
pital. 

All CPR instructors' courses ap- 
proved by the American Heart 
Association require that a special 
training mannequin, "Recording 
Resusci-Anne," be used to give 
students visual and recorded evi- 
dence of their performance. LCDR 
Bell had four mannequins: three 
were on loan for the day, but the 
fourth had recently been donated to 
the hospital by a local wives' club. 




• »... ,;,..;■« 



LCDR Bell (second from left) demonstrates CPR technique on mannequin 



23 



Clinical Notes 



Simplified Record-Keeping for a Centralized 
Intravenous Admixture Program 

LCDR Larry L. Karch, MSC, USN 
LCDR W. Frank Morris, Jr., MSC, USN 
LT Walter A. Ollenburg, MSC, USN 



The Pharmacy Service of Naval 
Regional Medical Center Charles- 
ton, S.C., started to implement its 
Centralized Intravenous Admixture 
Program in February 1975. First, 
we prepared intravenous admix- 
tures for continuous therapy, such 
as electrolytes and mixtures for pro- 
viding total nutrition by parenteral 
routes. We introduced the new ad- 
mixtures to one ward at a time until 
all wards were using them. 

In July 1975, we began the 
second stage of the program: pre- 
paring intravenous admixtures, 
such as antibiotics and antineoplas- 
tics, which are administered inter- 
mittently from partially filled mini- 
bottles and "piggyback" adminis- 
tration sets. Again, we worked with 
one ward at a time until all wards 
were using the new admixtures. 

Under the program, one phar- 
macy officer and a pharmacy techni- 
cian provide intravenous admixture 
service from 0730 to 1630 daily. 

When we planned the program, 
we designed a two-part intravenous 
admixture order form (Figures 1 
and 2) composed of a top sheet 
made from soft paper and a hard 
cardboard copy underneath. We 



LCDR Karch, formerly chief of the Phar- 
macy Service at Naval Regional Medical 
Center Charleston, is now chief of the Phar- 
macy Service of Naval Regional Medical 
Center Newport, R.I. 02840. LCDR Morris is 
chief, and LT Ollenburg is a staff pharmacist, 
at the Pharmacy Service, Naval Regional 
Medical Center Charleston, S.C. 29408. 



also developed an intravenous ad- 
mixture schedule card (Figure 3) 
duplicated from the back of DD 
Form 1348, a type of supply requisi- 
tion. 

The original, soft copy of the in- 
travenous admixture order stays in 
the patient's chart on the ward, 
while the hard copy is taken to the 
pharmacy. There the order is evalu- 
ated, a schedule card is prepared, 
labels are typed, and the hard copy 
is filed. The labels are then clipped 
to the schedule card, which is filed 



~ — 

=P 1 1 



in front of an index tab indicating 
the time the next bottle scheduled 
on that card must be administered. 
As each admixture is prepared, the 
manufacturer's name, the medica- 
tion lot number, and other pertinent 
information are recorded on the 
back of our file copy of the order 
form. 

Orders telephoned to the phar- 
macy are recorded on a schedule 
card. When the first dose is de- 
livered to the ward, the dose is 
compared with the physician's orig- 



— H 

Z 

— ■ ■ ' — 

, . — . — ■ 



Figure 1. Front of intravenous admix- Figure 2. Back of intravenous admixture 
ture order form. order form. 



. 



Ward 



Dr. 



Solution 



Rate of - 



Additives_ 

«. 

ft 

n 



Comae nts 



_*5_ 
#6 



#10_ 



#11 



_'3_ 
_#6_ 

#12 



IMTRAYEHOUS ADMIXTURE SCHEDULE CAHD 

Figure 3. Intravenous admixture schedule card before revision. 



24 



U. S. Navy Medicine 



inal order in the patient's chart be- 
fore the admixture is released. Then 
the hard copy of the order is taken 
to the pharmacy and filed, after the 
manufacturer's name, the drug lot 
number, and other pertinent infor- 
mation are written on the back. 



Patient_ 



J-'ar^. 



Data 



-J*'- 



Solution 



_Rats of Ainln. 



MdittwM. 



_!lunber: 



CHANGES 

We soon found that on new I.V. 
admixture orders the first bottle we 
prepared was often the second, 
third or fourth bottle the patient 
received. This happened when phy- 
sicians decided to start a patient 
immediately on an I.V. admixture, 
or when I.V. admixture service was 
not available. Nurses would then 
prepare the admixture right on the 
ward, and the patient had already 
been given several bottles by the 
time we received the order. Thus, 
the bottle marked #1 on our sched- 
ule card was not really the first 
bottle the patient had received. 
Consequently, we eliminated the 
printed numbers from the card — 
leaving only blank lines — so we 
could number each bottle accurately 
(Figure 4), 

Preparing intravenous admix- 
tures for intermittent administration 
caused a big increase in our work- 
load, which led to further changes 
in the program. We realized that we 
were spending too much time re- 
trieving the hard copy of the order 
form from our files solely to record 
the manufacturer and lot number 
for each bottle we prepared. We 
solved this problem by printing 
blocks on the back of the schedule 
card (Figure 5) so we could use this 
card, instead of the order form, to 
record the manufacturer, medica- 
tion lot number and other pertinent 
information. At the same time we 
added extra lines to the front of the 
schedule card so that more doses 
could be scheduled and recorded. 

Another change was made when 
it became apparent that most of our 
"piggyback" orders were for the 
same medications and similar 
doses. We pre-printed labels so that 
the only information we have to type 
in is the patient's name, ward, and 



HHRA73I0US aXMUniHB SCHZOTLE CUH) 

Figure 4. Revised schedule card. 



MB 


DRUG, CMC. , 


DRUG, COHC. , 


DRUG, CONC. , 
(JTY. 


DRUG, COSC. , 

<8I, 


DRUG, C05C. 
QTY. 


"piIT 


















HFR./LOT HO. 


HFR./LOT HO. 


MTF./LOT HO. 


MFR./LOT HO. 


MFR./LOT HO. 














































Figure 5. Back of schedule card. 

the administration time, dose, and 
volume of medication. 

For hyperalimentation orders, we 
designed a streamlined order form 
(Figure 6) which also serves as a 
pharmacy worksheet because it has 
blocks for recording the manufac- 
turer and lot number. After a physi- 
cian writes a hyperalimentation 
order, the order form is delivered to 
the pharmacy, where we make a 
copy for pharmacy files. The origi- 
nal order is returned to the ward to 
be attached to the patient's chart. 

Two wards are now on a modified 
unit-dose program. I.V. admixture 
orders for these areas are trans- 
ferred directly from a copy of the 
physician's original order to the 
intravenous admixture schedule 
card, obviating the need for the 
order form. Someday we may no 
longer need the order form for any 
I.V. admixture. 

We believe that more changes, 
either by design or of necessity, are 
inevitable to keep our program 
running smoothly. 



HTFEHiLWENTATTUK <litpK|[ fOflH 



Bj£E S3 LOTTOS: !..?.% Freaaiiw H in 2$ Eteftroaa — lHKnl. 
{Obtained by miring 5DCH1. tnuin IT «*! JOOal. 4t(t Dejctraae) 
TJia MiiklL&iit Litar of ■Qlutlm uil^hire :fn follow lilt; approxiiAte 
coapeeltiori; FftAjninc II (Amino Add Solurkm) . . «I J a f\ 

SodiLcn BuTitfiie U.SJ. fcu thin p,j j mjt. 

Hydra*! Dtnrnr UjS.P 100 f A 

Whit for InffcuML U.S. r. q.i. 

UKtnlyui (mEq.Jl): Sodium $-, rhaioluie 10 



I. iluic ■alutlan (cha;fc 
D, QLnnLitj/Flov Ratal 



•>. 



Prepare 

to b« admin ia I 

ni, Duratisn of Order: (Chuck tnc): 



. Prepare aa above 

_ Prepare lltara af i,.2& IVnutLw II In 

% JtextrMa (consult Phaj^asr Ftnrt-1 
toUlei af ii-f^jiij-.t^ ana liter per BoHlfl 

1 ■*■ —J^-i wr hour 

.. Sand Si. bkjur supply oql^ 



land bottlai Kith addit-lYes bcliru, 



_ Baaa solution abori 

Scdiua Chloride 

Potassium Chl/wide 

Celsius Cliiceptatc 
Ma pi raids Sulfa" 
Hvi ':<.:■! :-.■ ■■( ;■ = -..■ 



3'i,-,e: 



_ Hm aolution bdoyi 

Solium f^loridi 

PolriBaliim SMpriai _. 

Sodiun AcEtat-e mLq 

FeluuiuB Fhcaphatp 

Other . 

_ Gaaa jolutlan above, add 

Sodium Thljjrido c£q 

Fot^aaiiiiD C tiler id* mi 

Scdiua. Aeatata ■Eg. 

Othar • _ — * 

" Sodlun 

re us = 
s<iJi-j= 

QtaUL 



.ilJ: 



ilutlon above, add: 
Acetate >T g , 




Physicians Signal m 



Figure 6. Hyperalimentation order 
form. 



Volume 68, August 1977 



25 



Professional 



The Technique of Transpyloric Feeding 



CDR Brian S. Saunders, MC, USN 
CAPT Reinald J. Chutter, DC, USN 
CAPT William M. Bason, MC, USN 



In 1967, 1970, and 1973, Rhea and associates (1-3) 
reported on the use of transpyloric intubation to feed 
premature or severely ill neonates for whom conven- 
tional enteric feeding techniques had been unsuc- 
cessful or hazardous. Although many infants have 
been fed by this technique (4), wider application of 
the method has been hindered by the difficulty of 
positioning the tubing in the duodenum or jejunum 
and by questions about the safety of the technique 
{5-9). We undertook this review to confirm what our 
experience has shown, that transpyloric feeding is 
not as simple as several reports (2-4) have implied. 

Transpyloric feeding offers several advantages 
over the gavage feeding method. First, the stomach 
is bypassed, greatly reducing the risk of vomiting 
and aspiration. Bypassing the stomach also elimi- 
nates the problem of gastric distention frequently 
seen when neonates are fed by gavage, and thus 
prevents the apnea and bradycardia associated with 
gastric distention (10). Because gastric emptying is 
frequently delayed in small or ill neonates, the 
amount of food these infants can consume by the 
alimentary route is limited. When adequate calories 
are provided by the transpyloric route early in the 
neonate's life, the need for hypercaloric formulas 
and nonalimentary feeding routes is reduced. In a 
small, controlled trial of gavage and transpyloric 
feeding, Wells and Zachman have shown that feed- 
ings may be started significantly sooner and that 
early weight gain is significantly greater in neonates 
fed by the transpyloric route than in neonates fed by 
gavage (11). 

Infants with respiratory distress from any cause 
may be fed safely by the transpyloric route, 
including patients using "open" techniques of 
assisted ventilation such as nasal prongs or con- 



CDR Saunders is a member of, and CAPT Bason chairman of, 
the Department of Pediatrics, Naval Regional Medical Center, 
Portsmouth, Va. 23708. CAPT Chutter is a member of the Dental 
Department at NRMC Portsmouth. 



26 



tinuous positive airway pressure given through a 
face mask. Physicians may continue transpyloric 
feeding while the infant is weaned from assisted 
ventilation and during endotracheal extubation of 
the neonate. 

Indications for transpyloric feeding are: 

• Birth weight less than 1500 gm. 

• Respiratory distress syndrome. 

• Respiratory distress secondary to any cause, in- 
cluding aspiration syndromes, pneumonia, pneumo- 
thorax, and surgery. 

• Assisted ventilation, especially with "open" tech- 
niques. 

• During weaning from assisted ventilation. 

• During endotracheal extubation. 

• Failure to tolerate gavage feedings, as shown by 
large gastric residuals and vomiting. 

• Apnea and bradycardia, especially the forms re- 
lated to gastric distention. 

METHOD 

To intubate transpylorically, two items are re- 
quired: a properly measured length of medical 
tubing, and a gold weight which is placed on the end 
of the tubing. 

A 0.5 gm gold weight facilitates placement of the 
tubing through the pylorus and into the small bowel. 
These weights are custom-made in a dental pros- 
thetics laboratory from readily available dental 
materials (see figure). The amount of gold required 
to manufacture each weight costs approximately $3 
at the current market value of $132 per ounce. 

The gold weight is swedged onto the end of a #5 
French feeding tube, and a feeding hole smaller than 
one -third the circumference of the tube is cut as 
close to the weight as possible. The prepared tubing 
is sterilized with ethylene oxide gas. 

Although polyvinyl chloride is the material used 
most commonly to manufacture medical tubing, 
several problems in its use have recently been 

U.S. Navy Medicine 



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| • | ; % , % , I , 

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CENTIMETERS 

Steps in the manufacture of a gold weight for transpyloric 
intubation: (top to bottom) wax pattern, rough casting, partly 
finished weight, and finished gold weight. 

recognized. Approximately 40% of the dry weight of 
polyvinyl chloride tubing is a plasticizer, Di-(2-ethyl- 
hexyl) phthalate, which leaches out of the tubing and 
may be absorbed in the infant {12). The toxicity of 
plasticizers is unknown. Furthermore, after expo- 
sure to the environment of the small intestine for a 
period as short as 24 hours, polyvinyl chloride tubing 
becomes much less flexible, and has been associated 
with traumatic perforation of the bowel [5,6,8). For 
these reasons, polyvinyl chloride tubing should not 
be used for transpyloric intubation. 

Silastic tubing, while apparently safe, is difficult 
to use because of its extreme flexibility. The proper 
positioning of silastic tubing requires an introducer 
catheter or wire (2,3,13); however, the introducer 
wire is unsafe and should not be used. 

Polyurethane tubing recently has been evaluated 
as a safe alternative for transpyloric intubation (14). 
It is apparently nontoxic and firm enough to pass 
without an introducer. We have seen that it does not 
deteriorate or change its physical properties after 
being exposed to the small bowel environment for as 
long as 44 days. 

The length of tubing required to place the tip into 
the stomach is estimated by measuring the distance 



from the tip of the neonate's nose to the tragus of the 
ear to the xyphoid process. If too much tubing is 
placed in the stomach, the tubing will coil and the 
intubation attempt will probably fail. The tubing is 
passed through the neonate's nose or mouth the 
premeasured distance and taped in place. After the 
patient is placed in the right lateral decubitus posi- 
tion for 10 minutes, an additional 15 cm to 20 cm 
of tubing are passed into the stomach. The tip 
should be in place in the small bowel within 10 to 15 
minutes; occasionally a longer time is required for 
the tubing to enter the small intestine. Position may 
be confirmed by X-ray or by the appearance of bile- 
stained material in the tubing. If the gold tip of the 
tubing is in the third portion of the duodenum or 
beyond, the position is satisfactory. Using this tech- 
nique, we have successfully intubated more than 
95 % of our patients who required transpyloric feed- 
ing. 

The tubing is taped in a gentle arc from the alae 
nasi so there is no stress on the alae nasi or the nasal 
septum. Careless taping may lead to necrosis of the 
nasal structures. 

FORMULA OSMOLALITY 

The maximum osmotic tolerance of the small in- 
testine is between 350 and 400 mOsm/kg (4,13). 
Commercial 20 kcal/oz formulas and breast milk 
have osmolalities of approximately 300 mOsm/kg 
and are suitable for transpyloric feeding (see table). 
All elemental (pre digested) formulas are hypertonic 
and must not be used. 

Formula osmolality is the sum of the osmolalities 
of all osmotically active particles in the formula. 
Renal solute load can be estimated from the for- 
mula's sodium, potassium, chloride and nitrogen 
content— the elements excreted by the kidney (15). 
Carbohydrates, major contributors to formula osmo- 
lality, are metabolized to carbon dioxide and water, 
and therefore do not contribute to the renal solute 
load. Thus, total solute concentration of a formula 
(osmolality) has little relation to renal solute load 
and, conversely, renal solute load does not describe 
total formula osmolality (15). For example, Preges- 
tamil, an elemental diet with a renal solute load of 
approximately 190 mOsm/kg, has a formula osmo- 
lality of approximately 715 mOsm/kg. The infusion 
of Pregestamil or another hypertonic formula direct- 
ly into the small intestine will cause severe diarrhea 
and loss of fluid and electrolytes. 

The small intestine is not a reservoir, so bolus 
feeding may induce reflux of formula into the stom- 



Volume 68, August 1977 



27 



TABLE. Osmolality of Several Formulas 



1 


=tenal Solute Load* 


Osmolality** 


Formula 


(mOsm/kg) 


(mOsm/kg) 


Similac 13 


104 


185 


Si mi lac 20 


156 


290 


Similac 24 


189 


357 


Similac PM 60/40, 


119 


306 


20 calories 






Enfamil 13 


82 


195 


Enfamil 20 


128 


293 


Enfamil 24 


152 


429 


(premature formula) 






SMA13 


59 


191 


SMA20 


91 


300 


SMA24 


110 


364 


Isomi! 20 


160 


200 


Pro-So-Bee20 


200 


252 


Nursoy 20 


128 


244 


Pregestamil 


194 


715 


Nutramtgen 


195 


468 


D 5 W 
D l0 W 
Breast milk 





260 





520 


100 


290 


Cow's milk 


282 


362 



'Calculated value (method used by Ziegler and Fomon, 15). 
**Mean measured values supplied by manufacturer. There is 
minor variability from batch to batch. 



ach. For this reason, an infusion pump is used to 
administer formula at a steady rate. An oral gastric 
tube is passed and the stomach is aspirated every 
two to four hours to check for reflux of formula. 
Ideally no formula should be seen in the stomach, 
although 1 cm 3 to 2 cm 3 of bile-stained secretions is 
common, and is acceptable. These secretions should 
be replaced through the gastric tube to prevent un- 
necessary electrolyte and fluid loss. 

Feedings for infants who weigh more than 1200 
gm may be started with 20 kcal/oz iso-osmotic for- 
mula, which should be infused at a steady rate cal- 
culated to give the infants their daily fluid needs. 
Once the infant's tolerance is demonstrated, the in- 
fusion rate may be increased. 

Great caution must be exercised in delivering for- 
mula to infants weighing less than 1200 gm, in whom 
the chance of reflux of formula and the risk of vomit- 
ing and aspiration are greater. Feeding should begin 
with half-strength formula, 10 kcal/oz (approxi- 
mately 150 mOsm/kg), infused slowly at a rate of 1 
to 2 cm 3 /hour. The volume of formula is increased 
slowly in amounts the infant can tolerate to reach the 



infant's fluid maintenance in 12 to 24 hours. After 
this level has been reached, caloric strength is in- 
creased gradually to 20 kcal/oz; the volume of 
formula is then increased to provide between 120 
and 150 kcal per kg per day. Again, the physician 
should check for reflux of formula into the stomach 
by using an oral gastric tube. 



COMPLICATIONS 

Since transpyloric feeding was introduced in 1970, 
several complications have been reported, particu- 
larly perforation of the small intestine when polyvi- 
nyl chloride feeding tubes are used (5,6,8). In these 
reports, perforation seems to be associated with 
manipulation of the stiff polyvinyl chloride tube after 
it has been in place for some time. 

Although reflux is rare with a properly placed 
transpyloric tube, when reflux does occur there is a 
great risk of vomiting and aspiration. Usually reflux 
occurs if the tube has slipped back into the proximal 
duodenum or stomach. Feedings should be stopped 
until the cause of the reflux can be determined. An 
X-ray of the abdomen will reveal the tube's position 
and any intra-abdominal pathology. If the tubing is 
out of place, it should be removed and a new tube 
passed. 

Transpyloric feeding has been suggested as a 
cause of necrotizing enterocolitis {5,12,16). In our 
series of patients, two (8.3 % ) of 24 infants developed 
necrotizing enterocolitis; both patients were 26 to 28 
weeks in gestation and weighed less than 1000 gm. 
The 8.3% incidence is not excessive when compared 
to the incidence of necrotizing enterocolitis reported 
in the literature for other high-risk populations (17). 

A complication which has not previously been 
reported occurred in one of our patients. A full-term 
infant with severe meconium aspiration syndrome 
was fed 20 kcal/oz formula at a rate of 150 kcal per 
kg per day via a transpyloric tube, and developed 
signs of upper intestinal obstruction on the fifth day 
of feeding. At this time the transpyloric tube was in 
the correct position as shown on an X-ray and was 
functioning properly. No formula was seen in the 
vomitus, and stools were being passed normally. 
When the transpyloric tube was removed on the 
sixth day, we saw that a large vegetative formula clot 
surrounded the tubing just above the feeding hole. 
The signs of upper intestinal obstruction disap- 
peared rapidly, and the infant recovered unevent- 
fully. The problem has not recurred in 30 subsequent 
intubations we have performed. 



28 



U.S. Navy Medicine 



SUMMARY 

Transpyloric feeding offers several advantages 
over gavage feeding and reduces the need for hyper- 
caloric formulas and intravenous feeding methods. 
However, contrary to several reports, the technique 
is not simple and has a number of problems. 

REFERENCES 

1. Rhea JW, Graham AA Jr, Akhmoukh F, Parthew CT: 
Effect of hyperbaric oxygenation on neonatal tetanus. J Fediatr 
71:33, 1967. 

2. Rhea JW, Kilby JO: A naso-jejunal tube for infant feeding. 
Pediatrics 46:36, 1970. 

3. Rhea JW, Ghazzawi O, Weidman W: Naso-jejunal feed- 
ing: An improved device and intubation technique. J Pediatr 82: 
951, 1973. 

4. Cheek J A Jr, Staub GF: Naso-jejunal alimentation for pre- 
mature and full-term newborn infants. J Pediatr 82:955, 1973. 

5. Loo SWH, Gross I, Warshaw JB: Improved method of 
naso-jejunal feeding in low-birth-weight infants. J Pediatr 85: 
104, 1974. 

6. Boros SL, Reynolds JW: Duodenal perforation: A compli- 
cation of neonatal naso-jejunal feeding. J Pediatr 85:107, 1974. 



7. Chen JW, Wong PWK: Intestinal complications of naso- 
jejunal feeding in low-birth-weight infants. J Pediatr 85:109 
1974. 

8. Hayherst EG, Wyman M: Morbidity associated with pro- 
longed use of polyvinyl feeding tubes. Am J Dis Child 129-72 
1975. 

9. Challacombe D: Bacterial microflora in infants receiving 
naso-jejunal tube feeding. J Pediatr 85:113, 1974. 

10. Hasselmeyer EG, Hon EH: Effects of gavage feeding of 
premature infants upon cardiorespiratory patterns. Milit Med 
136:252, 1971. 

11. Wells DH, Zachman RD: Nasojejunal feedings in low- 
birth-weight infants. J Pediatr 87:276, 1975. 

12. Hillman LS, Goodwin SL, Sherman WR: Identification and 
measurement of plasticizer in neonatal tissues after umbilical 
catheters and blood products. N Engl J Med 292:381, 1975. 

13. Rhea JW, Ahmad MS, Mange WM: Nasojejunal feedings: 
a commentary. J Pediatr 86:451, 1975. 

14. Saunders BS, Chutter RF, Bason WM: Evaluation of poly- 
urethane tubing for transpyloric intubation and feeding. Am J 
Dis Child, to be published. 

15. Ziegler EE, Fomon SJ: Fluid intake, renal solute load, and 
water balance in infancy. J Pediatr 78:561, 1971. 

16. Heird WC: Nasojejunal feeding: a commentary. J Pediatr 
85:111, 1974. 

17. Frantz ID, L'Heureux P, Engel RR, Hunt CE: Necrotizing 
enterocolitis. J Pediatr 86:259, 1975. 



DON'T MISS 



The Consequences of Captivity 



Captivity has been a part of 
armed conflict from the beginning 
of recorded history. Yet it was only 
within the last three decades, in 
1949, that a major turning point in 
the treatment of captives was 
reached with ratification of the rules 
of the Geneva Convention. 

In a Navy-sponsored study, "Uni- 
versal Consequences of Captivity: 
Stress Reactions Among Divergent 
Populations of Prisoners of War and 
Their Families," Dr. Julius Segal, 
Dr. Edna J. Hunter, and Zelda 
Segal provide an overview of recent 
literature documenting the effects 
of this profoundly stressful experi- 
ence. The authors point out that the 
effects of captivity are relatively 
constant across nations and cul- 
tures: as a rule, the physical, 
psychological, and social costs of 
incarceration are predictable, no 
matter what nations are involved as 
captor and captive. 

Repatriated PO Ws of all nations 



appear to have difficulty reintegrat- 
ing themselves into their families 
and society. Many returned prison- 
ers are somewhat detached, lacking 
spontaneity and incapable of main- 
taining a sustained interest in any- 
thing. This apathy places an addi- 
tional strain on a family already 
reeling under the stresses of re- 
establishing marital and parental 
relationships. Often overlooked are 
the problems the wife and children 
experience in reopening their lives 
to a long-absent husband and father 
they have learned to live without. 

It is clear from published re- 
search — particularly from data pre- 
sented in 1961 at the International 
Conference on Later Effects of Im- 
prisonment and Deportation— that 
survivors of the POW experience, 
regardless of their national origin or 
the country in which they were held 
captive, are at risk for a staggering 
range of physical disabilities and 
symptoms. One example: long- 



lasting detrimental effects of mal- 
nutrition and starvation, found 
among British and Canadian troops 
captured by the Japanese as well as 
among repatriated Japanese PO Ws 
who scavenged for food while 
hiding after Japanese forces lost the 
Philippine Islands. 

The authors show evidence that, 
in spite of attendant privations and 
persecutions, captivity has led 
many individuals to develop a finer 
sense of self-worth and a keener 
appreciation of life's values. Count- 
less men and women, subjected to 
the malignant and cataclysmic ex- 
perience of captivity, have been 
able to turn that experience into an 
instrument for growth and emo- 
tional maturation. 

This study was published in the 
International Social Science Journal 
28(3):593-609, 1976. Reprints are 
available from the Naval Health Re- 
search Center, San Diego, Calif. 
92152. Ask for Report 75-84. 



Volume 68, August 1977 



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